2019 Medicare Limits: Coverage, Eligibility, Costs and More

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.

Do Medicare benefits run out?

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.

• For the first 60 days of a qualified inpatient hospital stay, you don’t have to pay any Part A coinsurance. You are responsible for paying your Part A deductible, however. In 2019, the Medicare Part A deductible is $1,364 per benefit period.
  
  
• During days 61-90, you must pay a $341 per day coinsurance cost (in 2019) after you meet your Part A deductible.
  
  
• Beginning on day 91 of your stay, you will begin using your “Medicare lifetime reserve days.” Medicare limits you to only 60 of these days to use over the course of your lifetime, and they require a coinsurance payment of $682 per day in 2019.

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.

Is there a limit on out-of-pocket Medicare spending?

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 $6,700 for in-network services and $10,000 for out-of-network services in 2019.

Medicare Advantage plans are offered by private insurance companies. They replace your Original Medicare coverage and offer 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:

• Routine hearing, dental and vision coverage
• Non-emergency transportation to approved locations
• Over-the-counter medication allowances
• Health and wellness programs, such as SilverSneakers

Depending on where you live, you may be able to find $0 premium Medicare Advantage plans.

What are the coverage limits during the Medicare Part D donut hole?

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.

• Once you and your plan combine to spend $3,820 on covered drugs in 2019, you will enter the donut hole.
  
  
• While you’re in the coverage gap, your plan limits its coverage for brand name drugs at 75 percent, and you pay 25 percent of the costs for brand name drugs. Your generic drug coverage is limited to 63 percent, which means you pay the remaining 37 percent of the costs.
  
  
• Once you have paid $5,100 in out-of-pocket costs for your covered drugs in 2019, you reach the limit of the donut hole and enter what is called the “catastrophic coverage” phase. During this phase, you pay a limited coinsurance or copayment for covered drugs for the rest of the year.

In 2020, you will enter the Part D donut hole after you spend $4,020 in out of pocket costs for covered drugs.¹

Once you enter the donut hole in 2020, you will pay no more than 25 percent of the costs for brand name drugs and generic drugs until you reach the catastrophic coverage phase.

Are there income limits for Medicare premiums?

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 standard Part B premium in 2019 is $135.50 per month for anyone with an income under the IRMAA limit.
  
  
• Part D premiums are dictated by the Part D plan carrier, but beneficiaries with an income over the IRMAA limit must pay an additional amount.

The limits are based on your reported income from two years prior, so the 2019 IRMAA is based on a beneficiary’s 2017 income.

The table below shows the Part B and Part D IRMAA amounts for various income limits.

Am I limited on where I can use my Medicare coverage?

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.

Find Medicare Advantage plans where you live

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.

Or call 1-800-557-6059 1-800-557-6059 TTY Users: 711 24/7 to speak with a licensed insurance agent.