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Hospital Clinic Visit Charges and Medicare Payments 2015

Find the average price for 28 types of hospital outpatient charges to Medicare patients. Includes average charge for 24 million Hospital Clinic Visits ($199) and average discount of 52%; Level 1 through Level 3 examinations (average charge from $109 to $1334, with discounts from 53% to 72%.) All other procedures (APCs) such as Endoscopy, nerve injections, ultrasound, EKG, MRI, Pulmonary Tests, Cardiac Imaging, Sleep Studies, Excision/Biopsy, Debridement, Noninvasive physiologic studies, eye tests, or electronic analysis of devices, have Medicare discounts from 63% to 90% off the charges. Example: Medicare paid $277 (including patient portion) on an average charge of $2867 for an MRI in CY 2015. Each state’s average is also shown. In a separate Excel file, find the average charge by hospital (excluding Critical Access Hospitals). Difficult to use, from CMS August 2017

Drug Coverage under Medicare, 2017 (pdf)

Five-page Tip Sheet explaining how prescription drugs, medicines and immunizations might be covered under Medicare Part B or Medicare Part D (the drug plan for seniors). Includes guidelines for cancer drugs, injectibles and IV drugs. Generally, Part A (hospital insurance) does not cover outpatient drugs. Publication 11315-P revised Aug. 2017

Indiana Medicare Prescription Drug Plan Costs (pdf)

Find monthly premium cost and annual deductibles for Medicare Prescription Drug Plans (Part D) in Indiana. Health insurance plans listed in alphabetical order in a 2-page PDF. Monthly premiums for 2018 range from $17.70 to $157.40. From

Medicare Part B Premiums and Part A Deductibles for 2018

CMS announced the standard Medicare Part B monthly premium will stay at $134.00 in 2018 for some ($1608 per year), with a $183 deductible. High income seniors will pay between $187.50 and $428.60 per month. CMS says about 5% of Medicare beneficiaries pay the high-income premiums for Part B. Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and other items. The Medicare Part A hospital insurance deductible will rise $24 to $1340. Released Nov. 17, 2017

Medicare Part D Drug Premium Costs for 2018

Based on the bids submitted by Part D Medicare prescription drug plans, CMS estimates that the average monthly premium that beneficiaries will pay for standard Part D coverage in 2018 will be $33.50. Reported August 2017

Medicare Personal Plan Finder (

This site helps you locate supplemental health insurance plans, find out their prices (premiums), and link to a page to check Medicare Eligibility. Generally, one has to be age 65 or disabled to qualify for Medicare. Early retirement at age 62 does NOT by itself allow someone to receive Medicare benefits

Medicare Prescription Drug Plans – Learn how they work (

Medicare’s help line for selecting a prescription drug plan (Medicare Part D) is 1-800-633-4227 (1-800-MEDICARE), or click on how to get drug coverage

MEDICARE TRUSTEES 2018 Report – hospital fund runs out of money in 2026

June 2018 report by CMS discusses the state of the Medicare Trust funds – a $710 billion program for 58.4 million people in 2017. Medicare expenditures alone are estimated at 3.7% of gross domestic product (2017). The depletion of the hospital trust fund is projected occur by 2026 (three years sooner than projected last year). In 2017, the average benefit per enrollee was $13,087.

Other Helpful Listings

Fact Sheet: Underpayment by Medicare & Medicaid (2016)

Analysis by the American Hospital Association shows that Medicare and Medicaid under-pay the true cost of hospital care by about $69 billion. This cost ends up being borne by other payors and commercial insurance. Using 2016 data, it is estimated Medicare pays 87 cents on the dollar, and Medicaid pays 88. December 2017 report

Healthcare Expenses for Seniors (MEPS 2011 data)

Special report on Health Care Expenditures for the Elderly Age 65 and over, shows median annual expenditures were $4206. Average expenses for those with expense were $9863 in 2011. Medicare paid over 62% (up considerably from 10 years ago); private insurance paid 16%; out-of-pocket amount declined to 12%. 96% of seniors had some healthcare expense, most often office-based care and prescribed medicines. Medications took up 22% of the total, averaging $76 per purchase. For seniors, the inpatient room rate averaged $3199 per day (sticker shock); ER visit was $884 on average; office visit was $228. MEPS Statistical Brief #429, Jan. 2014

Medicare Coverage for Colonoscopy or other Colon Cancer Screens

Annual FOBTs are free under Medicare. Other more expensive colon cancer screening tests such as colonoscopy and sigmoidoscopy are covered periodically, without cost to the patient if your doctor accepts Medicare assignment as full payment. Find out Medicare’s details. Unfortunately, Medicare does not provide cost estimates for the public at this site

Medicare Prescription Drug Plans – Premiums and Quality Ratings Editor's Pick

Compare the prices (monthly premium average cost) for prescription drug coverage through Medicare ( and see which plans have higher ratings. Uses a 5-star quality rating system that includes member satisfaction survey reports. 2018 premiums available for open enrollment ending Dec. 7, 2017

Medicare Value-Based Programs

Outline of Medicare’s four original value-based programs: Hospital Value-Based Purchasing, Hospital Readmission Reduction, Physician Value-Based Modifier program, and Hospital Acquired Conditions Program. Also End Stage Renal Disease (ESRD), Skilled Nursing Facility and Home Health Value-based programs.

Physician Payments: Average Medicare payment for 25 Common Office visits

Difficult file to use for find out what Medicare paid for certain types of office visits and procedures in 2012. Average doctor’s price is NOT SHOWN, but only the allowed amount determined by Medicare, and how much Medicare paid on average (for every state). Must know how to use Excel files and billing code knowledge also helpful. Medicare paid $49 for a 99213 office code (15 minute office visit for an established patient) and $73 for a 25-minute office visit, and just $101 for a 60-minute visit (est. patients). If the patient was new, Medicare paid $73 on average for a 30 minute visit, and $116 for 45 minutes. Medicare’s annual wellness visit was paid at $165 for new enrollees, then $111 for subsequent annual visits. The most common EKG was paid at $14, ear wax removal at $36, pneumonia or annual flu shot at $23. Terribly dated; last updated Sept. 2013

Physician: Average Cost for 25 Common Ambulatory Surgery Center Procedures

Difficult file for consumers to use unless familiar with Excel. Allowed amounts (rather than prices) in the Ambulatory Surgery file for 25 Common high volume outpatient surgical procedures in a Surgery Center, shows what Medicare paid during 2012 for cataract surgery, different types of endoscopy, spinal injections, some hernia repairs, carpal tunnel release, kidney stone crushing, prostate biopsy (avg $530 paid on $670 allowable charge), correction of bunion, and more. Uses CPT codes, and all states are listed. Terribly dated; last updated Sept. 2013

Previously Uninsured Have Higher Medicare Expenses – 2009

Link to Pubmed abstract in December 2009 Annals of Internal Medicine on study of 4567 adults who didn’t have insurance prior to enrolling in Medicare. Once acquiring coverage, those with diabetes, heart disease or joint replacements had 21% higher medical expenditures through Medicare, than those who were previously insured. Article by McWilliams, Meara et al.

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