As a Medicare beneficiary, you might wonder if there are any limits on your coverage.
There are certain limits to what Medicare covers, when you can enroll, the costs you might pay and more.
Here is a breakdown of some of these types of Medicare limits and how they might affect you.
If you are admitted for inpatient care at a hospital or another inpatient facility, your Medicare Part A (hospital insurance) benefits will help pay for some of your hospital costs.
Depending on how long your inpatient stay lasts, there is a limit to how long Medicare Part A will cover your hospital costs.
You only get 60 lifetime reserve days, and they do not reset after a benefit period or a calendar year. If you have a hospital stay that lasts longer than 90 days after your lifetime reserve days are exhausted, you will be responsible for all costs beginning on day 91.
There is no out-of-pocket spending limit with Original Medicare (Medicare Part A and Part B).
Medicare Advantage (Medicare Part C) plans, however, do feature an annual out-of-pocket spending limit for covered Medicare expenses.
While each Medicare Advantage plan carrier is free to set their own out-of-pocket spending limit, by law it must be no greater than $7,550 in 2021. Some plans may set lower maximum out-of-pocket (MOOP) limits.
Medicare Advantage plans are offered by private insurance companies. When you enroll in a Medicare Advantage plan, it replaces your Original Medicare coverage and offers the same benefits that you get from Medicare Part A and Part B.
Most Medicare Advantage plans provide prescription drug coverage, which is not typically covered by Original Medicare.
Some Part C plans also offer other benefits that Original Medicare doesn’t cover, which may include:
Depending on where you live, you may be able to find $0 premium Medicare Advantage plans.
Medicare Part D prescription drug plans feature a temporary coverage gap, or “donut hole.” During the Part D donut hole, your drug plan limits how much it will pay for your prescription drug costs.
Medicare Part B (medical insurance) and Part D have income limits that can affect how much you pay for your monthly Part B and/or Part D premium.
Higher income earners pay an additional amount, called an IRMAA, or the Income-Related Monthly Adjusted Amount.
The limits are based on your reported income from two years prior, so the 2021 IRMAA is based on your 2019 income.
The table below shows the Part B IRMAA amounts for various income limits.
2019 Individual tax return | 2019 Joint tax return | 2019 Married and separate tax return | 2021 Part B monthly premium |
---|---|---|---|
$88,000 or less |
$176,000 or less |
$88,000 or less |
$148.50 |
More than $88,000 and up to $111,000 |
More than $176,000 and up to $222,000 |
N/A |
$207.90 |
More than $111,000 up to $138,000 |
More than $222,000 up to $276,000 |
N/A |
$297.00 |
More than $138,000 up to $165,000 |
More than $276,000 up to $330,000 |
N/A |
$386.10 |
More than $165,000 up to $500,000 |
More than $330,000 up to $750,000 |
More than $88,000 up to $412,000 |
$475.20 |
More than or equal to $500,000 |
More than or equal to $750,000 |
More than or equal to $412,000 |
$504.90 |
The table below shows the Part D IRMAA amounts for various income limits.
2019 Individual tax return | 2019 Joint tax return | 2019 Married and separate tax return | 2021 Part D monthly premium |
---|---|---|---|
$88,000 or less |
$176,000 or less |
$88,000 or less |
Your plan premium |
More than $88,000 and up to $111,000 |
More than $176,000 and up to $222,000 |
N/A |
$12.30 + your plan premium |
More than $111,000 up to $138,000 |
More than $222,000 up to $276,000 |
N/A |
$31.80 + your plan premium |
More than $138,000 up to $165,000 |
More than $276,000 up to $330,000 |
N/A |
$51.20 + your plan premium |
More than $165,000 up to $500,000 |
More than $330,000 up to $750,000 |
More than $88,000 up to $412,000 |
$70.70 + your plan premium |
More than or equal to $500,000 |
More than or equal to $750,000 |
More than or equal to $412,000 |
$77.10 + your plan premium |
Original Medicare can be used anywhere in the U.S. and in certain U.S. territories, as long as you visit a provider who is enrolled in Medicare and who accepts new Medicare patients.
Some private Medicare plans such as Medicare Advantage plans and Part D plans may feature provider or pharmacy networks that limit the providers you can visit for covered services.
For more information on how your plan networks work and how to find a Medicare provider near you who accepts your plan, be sure to check with your plan carrier.
If you have any questions about the Medicare Advantage plans that are available near you and the network coverage they offer, you can call to speak with a licensed insurance agent.
A licensed agent can help you find out if your doctor is part of plan networks available near you, and they can also help you see if your prescriptions drugs are covered by any available plans.
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