Yes, Medicare has copays, and they vary by plan type and service

Medicare is not free. You will pay money when you use most services — either upfront at the doctor's office or through monthly premiums. The amount depends on which Medicare plan you have (Original Medicare or a Medicare Advantage plan), what service you're getting, and whether you've met your deductible for the year.

The three main out-of-pocket costs are copays (a fixed dollar amount per visit), coinsurance (a percentage of the cost you pay after Medicare pays its share), and deductibles (what you pay before Medicare coverage kicks in). Original Medicare and Medicare Advantage plans structure these costs differently, so knowing which plan you have matters.

Key Takeaways

  • Original Medicare Part A has a deductible for hospital stays but no copay for most inpatient care; Part B has a deductible and then you pay 20% coinsurance for most services.
  • Medicare Advantage plans set their own copays and deductibles, which can be lower or higher than Original Medicare depending on the plan.
  • Preventive services like annual wellness visits and cancer screenings have no copay under either plan type.
  • If you have limited income, you may be able to reduce your out-of-pocket costs through programs like the Medicare Savings Program or Extra Help.
  • Prescription drug coverage (Part D) has its own deductible, copays, and coverage gaps that change each year.

How copays work in Original Medicare

Original Medicare (Parts A and B) does not use copays the way private insurance does. Instead, you pay a deductible and then coinsurance. For Part A (hospital insurance), the deductible applies per hospital stay — in 2024 it is $1,676, though this amount changes yearly. Once you meet that deductible, you pay nothing for the first 60 days of a hospital stay. Days 61 through 90 cost you a daily amount set by Medicare.

For Part B (medical insurance), you pay a yearly deductible (in 2024, $240) and then 20% coinsurance on most services after that. So if your doctor charges $100 for an office visit and Medicare approves $80, you pay $16 (20% of $80). The doctor may also bill you for the difference between what they charge and what Medicare allows, called balance billing, unless they accept Medicare assignment.

Some services in Original Medicare do have fixed copays. Outpatient mental health visits cost you $20 per session. Outpatient physical therapy and occupational therapy have a copay of $20 per visit (up to a yearly limit). These are exceptions, not the rule.

How copays work in Medicare Advantage plans

Medicare Advantage plans (Part C) are run by private insurance companies and work more like traditional health insurance. Each plan sets its own copays, coinsurance, and deductibles. One plan might charge $15 for a primary care visit and $40 for a specialist; another might charge $30 and $60. You need to check the specific plan's documents to know what you will pay.

Most Medicare Advantage plans have lower copays than the 20% coinsurance you'd pay in Original Medicare, which is why many people choose them. However, they also have a yearly out-of-pocket maximum — once you reach it, the plan pays 100% of covered services for the rest of the year. Original Medicare has no out-of-pocket maximum, so your costs can keep climbing.

Medicare Advantage plans must cover everything Original Medicare covers, but they can add extra benefits like dental, vision, or hearing. Those extras often come with their own copays or limits.

Services with no copay under any Medicare plan

Medicare covers certain preventive services at no cost to you, regardless of whether you have Original Medicare or Medicare Advantage. These include your annual wellness visit (sometimes called a "Welcome to Medicare" visit if you're new to Medicare), colorectal cancer screening, mammograms, prostate cancer screening, and flu shots. You pay nothing for these services as long as you see an in-network provider and the service is considered preventive.

The catch: if your doctor finds something during a preventive visit and needs to do additional testing or treatment, that follow-up care is not free. For example, a colonoscopy screening has no copay, but if the doctor removes a polyp during the procedure, you may owe coinsurance for the removal.

Prescription drug copays under Part D

Prescription drug coverage (Part D) is separate from Parts A, B, and C. It has its own yearly deductible, copays, and a coverage gap. In 2024, the deductible can be up to $505, though many plans have lower deductibles. After you meet the deductible, you pay a copay or coinsurance for each prescription — typically $5 to $15 for generic drugs and $15 to $50 for brand-name drugs, depending on the plan.

Once you and your plan have spent a combined $5,380 on covered drugs in 2024, you enter the "donut hole" or coverage gap. In this gap, you pay a higher percentage of the drug cost until you reach the catastrophic coverage level. After that, you pay a small copay and Medicare covers the rest. The dollar amounts and percentages change each year.

If you have a Medicare Advantage plan that includes drug coverage (Part D), the copays are built into that plan's structure. If you have Original Medicare, you choose a separate Part D plan from a private insurance company.

How to reduce your out-of-pocket costs

If your income is low, you may be able to reduce your copays and deductibles through the Medicare Savings Program. This program, run by your state, can pay some or all of your Part A and Part B premiums, deductibles, and coinsurance. Income limits vary by state, but generally you must have income below 150% to 200% of the federal poverty level. Contact your state Medicaid office or call 1-800-MEDICARE to learn about you may have access to.

For prescription drugs, the Extra Help program (also called the Low-Income Subsidy) can lower your Part D premiums, deductibles, and copays if your income and resources are below certain limits. You can explore through Social Security or at ssa.gov.

Some pharmaceutical companies offer copay information cards that reduce what you pay at the pharmacy for specific brand-name drugs. Ask your doctor or pharmacist whether your medications have these programs available.

What to expect when you receive a bill

After you see a doctor or use a service, you will receive an Explanation of Benefits (EOB) from Medicare or your Medicare Advantage plan. This document shows what the provider charged, what Medicare or your plan approved, what they paid, and what you owe. The EOB is not a bill — it is a record of what happened. The actual bill comes from the provider.

If you disagree with a charge or think there's an error, you have the right to appeal. Original Medicare appeals go through Medicare; Medicare Advantage appeals go through your plan. Both processes are free, and you have a set timeframe to request an appeal (usually 60 days from the date on the EOB).

Frequently Asked Questions

Do I pay copays for emergency room visits?

In Original Medicare, you pay the Part B deductible (if you haven't met it) and then 20% coinsurance for emergency room services. In Medicare Advantage, you pay whatever copay your plan lists for emergency care — often $150 to $300. If you're admitted to the hospital from the ER, the hospital stay deductible applies instead.

What happens if I go to an out-of-network doctor?

In Original Medicare, you can see any doctor who accepts Medicare, and your copay or coinsurance is the same. In Medicare Advantage, going out-of-network usually costs you more — sometimes much more — or may not be covered at all. Check your plan's network before scheduling.

Do I have to pay copays for lab tests?

In Original Medicare, you pay 20% coinsurance for lab tests after you meet your Part B deductible. In Medicare Advantage, copays for lab work vary by plan — some charge $0, others charge $10 to $50. Check your plan documents or call the plan to find out.

Can my copay change during the year?

In Original Medicare, copays and coinsurance amounts are set by Medicare and don't change mid-year, though they do change each January. In Medicare Advantage, your plan's copays are locked in for the year you enrolled, but they can change the following January when your plan renews.

What if I can't afford my copays?

Talk to your doctor's office or hospital billing department about payment plans or financial hardship programs. Some providers offer discounts for uninsured or underinsured patients. You can also look into the Medicare Savings Program or Extra Help if your income qualifies — these programs can significantly lower your out-of-pocket costs.