How does a person calculate the out of pocket costs for Medicare Part B? ie the copayments?

Question

I need to know how to calculate the out of pocket expenses for medicare part B after my deductible is met? Is there a formula that I can use? How do I know how much medicare allows the Dr to charge? For example, the Dr charges $300 for an office visit, medicare allows, lets say, $17, do I pay the difference? or another amount? I would like to know what I am going to be hit with before it hits me. I know that Medicare Part B is based on an 80%/20% format. I am really confused and the Medicare web site did not address how to calculate. Thanks.

Answer 1

Copayments are 20% of the allowable charges by Medicare

Answer 2

What state are you in??  Each state has different rates but the fee schedule should be posted online.  At least in NY and NJ they are.  After your deductible you are responsible for 20% of the allowable amount.

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Example:

Dr. charges $200.00 but Medicare allows only $100.00, your deductible is met so Medicare pays $80.00 and you are responsible for $20.00 only.  That extra $100.00 that the doctor charged will be written off.  The doctor is not allowed to collect it if s/he is a participating provider with Medicare.  You will receive an explanation of benefits (EOB) when medicare finishes reviewing the claim submitted by your doctor and it will detail the exact amounts that are paid by you, by Medicare and what should be written off.

Answer 3

You really don't need to know how to calculate it.  Just wait for the EOB and it will tell you what was allowed and what way paid.  If your Dr accepts Medicare "assignment" they can not charge more than the 20% co-pay.  If they do not accept assignment, they can charge you more, but are limited by Medicare as to the maximum.  Your part is always based on the amount Medicare allows, not what the doctor charges.

Answer 4

If the part B service you're receiving is paid @ 80%, you won't really have a way to know what your 20% will be until medicare pays your claim. Some doctor's offices may know what the reimbursement will be, based on claims paid to them for other patients. Medicare is still working on putting together a fee schedule on the internet.

As long as you see a medicare approved doctor, you only pay 20% of the amount medicare allows. So, using your example above... IF medicare allows $17,

you pay 20%= $3.40

& medicare pays 80%=$13.60

and, the difference is the doctor's "discount". No one pays it.

hope this helps

Answer 5

I understand your frustrations but it's hard to know what the doctor is going to charge you before you are seen.  Medicare has an allowable amount that your physician has agreed to accept so when you go to the doctor they will find the allowable amount for each charge and calculate 20% of that to get your coinsurance.  This amount varies because the level of office vist ranges depending on the level of service documented/performed and if any additional test are done.  If you can locate the Medicare fee shchedule for your state you can look at all the 99201- 99215 codes.  Those are the office visit codes.  If you calculate your coinsurance on those fees then it will give you a range of what you can expect to pay for your office visit.  Keep in mind that when other services are done such as checking your sugar or urine then additional fees will be added.