How to lower your Medicare doctor copays

Copays for doctor visits can add up, especially if you get injured, sick, or develop a chronic illness. Depending on the Medicare Advantage plan you belong to, you may be paying anywhere from $10 to $45 (or more) each time you visit your primary care physician or a specialist. If your out-of-pocket costs are higher than you’re comfortable with, it may be time to consider other Medicare plans.

Medicare Benefits Solutions

Sep 2, 2021

 5 minutes read

Copays are just one of the out-of-pocket expenses you’re responsible for when you’re enrolled in a Medicare Advantage plan. Unlike coinsurance, copays are usually a fixed amount you have to pay each time you visit a physician. Copays can vary based on what plan you have and where you live. If you experience a change in your health requiring you to see doctors more often, the cost of copays could feel overwhelming.

If the answer to any of these questions is “too much,” you may want to check out other plans available in your area. You may find a different MA plan with lower doctor copays that still includes the comprehensive care you deserve.

Medicare Advantage plans vary in deductibles, premiums, copays, and annual out-of-pocket maximum limits. Even MA plans from the same insurance company can differ in costs and benefits. Compare MA plans to help you determine if there is a different plan that may better suit your current needs. Online, side-by-side plan comparison tools make it easier than ever to make sure you still have the Medicare coverage that’s right for you. If you find a plan you’d like to switch to, you may be able to make a change during a Medicare enrollment period.


The type of MA plan you choose may affect your copays

Some of the most popular Medicare Advantage plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Special Needs Plans. Let’s take a look at how doctor copays may differ among these plans.


Health Maintenance Organizations: If you enroll in an HMO, you may have to visit doctors and specialists within your plan’s network of providers. Many HMOs require you to visit your primary care physician to get a referral to a specialist. You’ll have a fixed doctor copay amount to pay at the time of service, and some plans may charge higher copays to see a specialist or get urgent care. If you choose to go outside the network for care, you may be responsible for 100% of the expenses incurred.

Preferred Provider Organizations: PPOs, on the other hand, may give you more flexibility. Like HMOs, you will likely pay a fixed doctor copay when you visit providers within the plan’s network, but some PPO plans will allow you to go to a doctor outside of the plan’s network for a higher copay.

Special Needs Plans (SNPs): If you have a Dual-eligible Special Needs Plan (D-SNP) because you qualify for both Medicare and Medicaid, your copays may be completely covered while seeing providers within the plan’s network. If you are not eligible for Medicaid and enroll in a Special Needs Plan due to specific care needs, your copay costs may depend on the plan you enroll in.

While Medicare Advantage plans are required by law to not charge more than Original Medicare for certain kinds of care, they may have higher copays for other services and supplies, like durable medical equipment (DME). If your copay amounts have been too high with your current MA plan, you may find that a different type of Medicare Advantage plan may be able to save you money.


When can you switch Medicare plans to get lower doctor copays?


You may be able to switch to a different Medicare Advantage plan during the following enrollment periods:

  • Annual Election Period (AEP): From October 15 through December 7, you can make changes to your Medicare coverage. If you choose to enroll in a new plan, your coverage will take effect on January 1.
  • Medicare Advantage Open Enrollment Period: From January 1 through March 31, you can make one change to your Medicare coverage and switch from one plan to another (or even revert back to Original Medicare.)
  • Special Enrollment Period (SEP): You may qualify for an SEP if you experience certain changes in your life. For instance, if you move out of your current plan’s service area, you will be able to switch plans the month before you move through two months after you move.

Take the next step to potentially lower your doctor copays

If your doctor visit copays are too high, compare the costs and benefits of other plans in your area. If you have questions along the way, a knowledgeable, licensed sales agent may be able to help you narrow down your options based on your needs and preferences and even help you enroll when you’re ready.

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