Beyond a $0 Medicare Premium: What Costs Might Still Be Yours?

A Medicare Advantage plan with a $0 monthly premium and free routine doctor visits can seem like a bargain. But what could you still pay for surgery, a hospital stay or ongoing treatment?

Many people who use insurance often still do not fully understand all of their benefits. Those who rarely need care may know little about expenses beyond a standard checkup. Open enrollment is the time to review your coverage and make changes before a bigger medical need arises.

Begin with your Annual Notice of Change, which is typically sent by September 30. It lays out this year’s costs and benefits alongside the changes that will take effect in January. If you cannot find it, ask your insurer for another copy or check the plan’s website.

Two additional documents are also useful. The Summary of Benefits offers a shorter look at coverage and charges. The Evidence of Coverage is the full member handbook describing covered services, your costs, limits and approval rules. Both are available from your insurer.

Plan changes differ, but these are the main items to review each year:

• Premiums and deductibles: Ongoing payments and the amount you must pay before coverage starts.
• Copays and coinsurance: Flat fees or percentages you owe for care.
• Hospital costs: Daily charges and the number of days they apply.
• Out-of-pocket maximum: Your yearly cap on covered medical cost sharing.
• Prescription coverage: Covered drugs, pricing and preferred pharmacies.
• Dental and other extras: Allowances, covered procedures and benefit limits.
• Networks and approvals: In-network doctors and hospitals, plus any treatment approvals needed in advance.

Recent plan changes have included lower dental allowances at some major insurers and higher prescription deductibles. Some plans are also increasing medical cost sharing while keeping $0 premiums. These changes are not universal, so each plan should be checked individually.

Consider a hospital stay: a plan that charges $665 per day for the first five inpatient days could leave you owing $3,325 in hospital copayments. Other services could add more.

An in-network medical out-of-pocket maximum of $7,150 provides protection, but it is still a sizable amount. Premiums, Part D drug costs and noncovered services are not included in that limit. It resets each calendar year. An illness that begins late in the year could count toward one year’s maximum and then begin counting again on January 1, even if the same condition continues.

Think about how much money you have available. If your budget allows, set up automatic transfers into a savings account reserved for medical expenses. Saving $100 a month would add up to $1,200 in a year. Building a reserve takes time, so it should go hand in hand with coverage you can afford.

A Health Savings Account, or HSA, is a special account that lets eligible people with qualifying health insurance save money with tax advantages for medical expenses. Once you are enrolled in Medicare, you can no longer contribute new money to an HSA. You may still keep an existing account and use its balance tax-free for qualified expenses.

Even without an HSA, a regular savings account remains an option for Medicare beneficiaries.

Medical bills can create major financial stress, even for insured people. A 2022 KFF survey found that about four in 10 U.S. adults had some form of debt from medical or dental bills.

Know Which Company Is Behind the Plan

Medicare Advantage plans are offered by private insurers. Nationwide, UnitedHealthcare and Humana together cover nearly half of Medicare Advantage members. Other major names include Aetna, which is owned by CVS Health; Kaiser Permanente; and Elevance Health. What is available depends on where you live.

Knowing the company name is only the starting point. One insurer may sell several plans with different hospital charges, dental benefits, prescription coverage and provider networks.

Reported plan changes illustrate why comparing individual options matters:

These details come from a national review of Medicare plan data reported by Healthcare Dive. They do not describe every plan and do not determine which company offers the best coverage in your county.

Understand Who Is Helping You Decide

Licensed insurance agents and brokers may sell Medicare plans and receive commissions. They can explain coverage and help with enrollment, but they may not represent every insurer or every plan available. Ask: “How many companies do you represent, and which plans are not included in your comparison?”

You may recall a rule that usually required a 48-hour wait between completing a Scope of Appointment form and a personal sales appointment. CMS removed that waiting period in its rule changes. The form still specifies which coverage types you agree to discuss, and filling it out does not enroll you in a plan.

Other safeguards still apply. Representatives generally cannot call or text without permission unless you are already a member of their plan, show up at your home uninvited, pressure you to enroll or ask you to sign anything before you are ready. They also must explain how many organizations and plans they represent before discussing specific benefits.

For help from someone who does not sell insurance, call SHICK in Kansas at 1-800-860-5260 or Missouri SHIP at 1-800-390-3330. Both offer free, unbiased Medicare counseling.

You do not have to sort through coverage alone. Free, unbiased Medicare counseling is available through SHICK in Kansas at 1-800-860-5260 and Missouri SHIP at 1-800-390-3330. Bring your plan documents and ask a counselor to explain what hospitalization, surgery and recovery may cost, and to help compare your options.

Medicare open enrollment ends soon, with changes taking effect January 1.