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Hospital Clinic and Office Visit Charges and Medicare Payments 2018

Find Hospital Clinic and Office Visit charges (average price) for 2018, and the payments that Medicare made. Find average charges for about 13,000 different codes (depending whether office or hospital facility-based).  National average prices are in the Procedure Summary file. Extremely difficult to use, even if somewhat familiar with using Excel files. File uses HCPCS codes. The most common codes were office visits 99213 (average charge about $138) and 99214 (average charge about $208). Medicare allowed about $71 for code 99213 and about $105 for 99214. Therapeutic exercise (code 97110) had average charge of $61, with Medicare allowing about $26. Lab tests, x-ray, emergency department visits are in the file. An Emergency Department visit (code 99285) had a national average facility charge of $1,118, with Medicare allowing just $174. Physician charges may be available in the Provider Summary Table. Calendar year 2018 data from CMS updated November 2020.

Drug Coverage under Medicare

Learn the basics on prescription drug coverage under Medicare. Six-page Tip Sheet explains how prescription drugs, medicines and immunizations might be covered under Medicare Part B, Medicare Advantage plans (Part C) 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 updated May 2020.

Medicare (Inpatient) Prices for Hospitalizations 2018

Medicare inpatient prices for hospitalizations during 2018 are in this difficult to use Excel file. Amounts paid to hospitals by Medicare, on average for FY 2018 hospital stays, are shown. Listed by DRG and provider. Consumers can see the Medicare volume for that diagnosis and how much the hospital was allowed as Covered Charges, plus what Medicare payments were. If you can wade through it, you’ll see that total payments were quite often only one-fourth of what the covered charges were – a 75% discount. Hence, the file illustrates how hospital pricing (charge) has become meaningless for most people. Here are a few examples. A hip or knee joint replacement at the Hospital for Special Surgery in New York City, had an average charge of $72,000 for over 4,000 cases. However, the total payment on average was just over $22,000, an effective discount of 69% of the total charges. The hospital with the second largest Medicare volume of hip and knee replacements, New England Baptist Hospital in Boston, had an average charge of about $24,000, and average total payment of $15,500. Their average discount was 35%. NorthShore University in Evanston, IL and NYU Langone Hospital in NYC, had effective discounts of 70% and 82% respectively. All four hospitals received total average payments for joint replacement (DRG 470), between $16,000 and $26,000, but average charges ranged from $24,000 to $141,000.

Medicare Advantage Plans Part C Premium Costs for 2021 (CMS)

CMS announced that the average Medicare Advantage plan (Part C) premium cost will decrease in 2021. There will be about 4,800 such plans for 2021 that are expected to enroll about 42 percent of Medicare beneficiaries. Medicare Advantage plan enrollment has been increasing in recent years as people switch from traditional Medicare. Plans vary widely by state and region. CMS estimates the average monthly rate will be $21 per month (plus what you will pay directly to Medicare for Part B). Medicare Advantage plans may or may not include Part D drug coverage. Read very carefully. For many consumers, there will be a $0 monthly premium. However, in all plans, there will be copays, deductibles, and out of pocket maximums to consider. At the end of the press release are links to actual premiums by name of health plans in each state. Press Release issued September 24, 2020.

Medicare Part B Premiums and Part A Deductibles for 2021

CMS announced the standard Medicare Part B monthly premium will be $148.50 (up $3.90) in 2021 for most recipients ($1,782 per year), with a $203 deductible (up $5). Part B premiums are up about 2.7% and the deductible is up about 2.5%. High income seniors will pay between $207.90 and $504.90 per month. CMS says about 7% 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 $76 (about 5%) to $1,484. Released Nov. 6, 2020.

Medicare Part D Drug Premium Costs for 2021

For 2021, the average basic Medicare Part D drug premium cost is expected to be about $30.50 per month, according to a CMS press release. However, CMS announced in a separate memo to drug plan sponsors, that the 2021 Part D base beneficiary premium is $33.06. Additionally, the Part D national average monthly bid amount from insurance companies for 2021 is $43.07. We were unable to reach CMS for clarification of the differing rates and which is most relevant to consumer experience. According to the press release, consumers who select a Part D “Senior Savings Model plan” will have insulin costs capped at a maximum $35 copay for a month’s prescription. Reported July 29, 2020.

Medicare Personal Plan Finder (medicare.gov)

The Medicare Personal Plan Finder site at medicare.gov 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 Part D works (Medicare.gov)

Learn how Medicare Prescription Drug Plans (Part D) work, from medicare.gov. 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 prescription drug coverage.

MEDICARE TRUSTEES 2020 Report – hospital fund runs out of money in 2026

The Medicare hospital insurance fund (Part A) runs out of money in 2026, according to the latest report from the Medicare Trustees. The April 2020 report by CMS discusses the state of each of the Medicare Trust funds – a $796 billion program for 61.2 million people in 2019. Medicare expenditures alone are estimated at 3.7% of gross domestic product (2019), same as last year. Part B (outpatient) and Part D (drug) have “sufficient financing” – i.e., they are in decent shape. However, the hospital trust fund is projected to be depleted by 2026 (the same as projected in  the last two years). As a caveat, the picture could actually be worse in light of the COVID-19 pandemic. The Medicare Board of Trustees was unable to adjust the estimates accurately at this time for the effects of the new coronavirus. The Trustees noted that the real picture could be worse than projected. The 2021 report could be more dire, with less time to fix the fund. In 2019, the average total Medicare benefit per enrollee was $13,879, up 4.7% from the prior year. [Note June 15, 2021: The 2021 Medicare Trust fund report is already 2 1/2 months overdue, which we think is not a good sign. Read more.]

Other Helpful Listings

Fact Sheet: Underpayment by Medicare & Medicaid (2021)

Analysis by the American Hospital Association shows that Medicare and Medicaid under-pay the true cost of hospital care by about $76 billion. This cost ends up being borne by other payers and commercial insurance. Using 2019 data, it is estimated Medicare pays 87 cents on the dollar, and Medicaid pays 90. January 2021 report.

Healthcare Expenses for Seniors (MEPS)

Healthcare expenses for seniors are outlined in this MEPS report on Health Care Expenditures for the Elderly Age 65 and over. Median annual expenditures were $4,206 per person (about $5,447 in 2020 dollars). Average annual expenses for those with expense were $9,863 in 2011. Using medical inflation rates, $9,863 is about $12,772 in 2020 dollars. Medicare paid over 62% (up considerably from 10 years earlier); 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 $3,199 per day (sticker shock, and over $4,100 in 2020 dollars); ER visit was $884 on average; office visit was $228. MEPS Statistical Brief #429 uses 2011 data, published Jan. 2014. Add about 30% to account for medical inflation to 2020.

Medicare Coverage for Colonoscopy or other Colon Cancer Screens

Learn what Medicare covers for colonoscopy or other screens for colon cancer. Annual fecal occult blood tests (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. Medicare also covers at-home multi-target stool DNA lab test (e.g. Cologuard) once every 3 years for certain people ages 50 to 85. Cologuard identifies altered DNA and/or blood in stool, which are associated with the possibility of colon cancer or precancer. Find out Medicare’s details. Unfortunately, Medicare does not provide cost estimates for the public at this site

Medicare Part D Prescription Drug Plan Ratings 2021

Theoretically, consumers should be able to compare the 2021 star ratings for over 800 health insurance plans that are part of the Medicare Part D Prescription Drug program at this site. But the files linked here are darn near impossible to use, even if you know Excel. Best bet is to review the Fact Sheet that shows the highest rated plans. Your second choice might be to review the overall summary file near the bottom of the zipped Data Table file download. Other files show performance scores including member ratings. But you will have to phone a friend with a PhD to help. From CMS, updated October, 2020

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

Medicare Prescription Drug Plans – Premiums and Quality Ratings for consumers. Compare the prices (monthly premium average cost) for prescription drug coverage through Medicare (medicare.gov) and see which plans have higher ratings. Uses a 5-star quality rating system that includes member satisfaction survey reports. The more accurate prices will be available if you create an account and log in. Part D plans for 2021 should be updated by early October, 2020, ahead of Medicare’s open enrollment October 15, 2020.

Previously Uninsured Have Higher Medicare Expenses

Research study shows that people who were previously uninsured, have higher Medicare expenses. Study of 4,567 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. Pubmed abstract in December 2009 Annals of Internal Medicine.

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