How do you explain to clients that "zero-premium" doesn't mean "zero-cost" with Medicare Advantage?

Question

Dana Dane · Accepted Answer

Benefits vary from plan to plan. Often times you may have a $0 copay with an in-network primary care physician, for example. There is usually cost sharing for out-patient surgeries, hospitalization, major diagnostic tests as well as other services. Cost sharing can be a set dollar amount or a percentage of the cost.

Answered by Dana Dane on April 2, 2025

Agent Licensed in OR, AZ, CA & 6 other states

Answered by Dana Dane Medicare Insurance Agent

Lt Col Tim Brown · Answer

Sometimes people hear what they want to hear. I cant tell you how many times I've told people something about a plan and then they repeat back what they thought they heard or what they really wanted it to be and I have to say "no that is not what I said". Words have meanings. Zero Premium means just that, no premium. I tell people that MAPD plans are co-pay driven, meaning you have co-pays as you use the plan. There is a max out of pocket, etc. People hear what they want to hear. I have to do my best to make sure that does not happen.

Answered by Lt Col Tim Brown on July 4, 2025

Broker Licensed in TN, AL, CO & 10 other states

Answered by Lt Col Tim Brown Medicare Insurance Agent

Gary Church · Answer

Explaining the zero premium means stating that you pay for the health plan through co-payments and deductibles. If hospitalized, consider the hospital stay's co-pays and meeting the MOOP. Office visits, outpatient services, and emergency room visits.

Answered by Gary Church on June 9, 2025

Broker Licensed in Ca, AZ, NV & TX

Answered by Gary Church Medicare Insurance Agent

Tony Capraro III · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/how-do-you-explain-to-clients-that-zero-premium-doesnt-mean-zero-cost-with-medicare-advantage#tony-capraro

William Lawler · Answer

A "zero premium" means that you will pay $0 per month for your Advantage plan. But, there will be co-pays and co-insurance if you use medical services. Advantage plans have a MOOP (maximum-out-of-pocket) ceiling on their plans. Each Advantage plan has different a MOOP. 
Bill Lawler 636-500-1892

Mark Maliwauki · Answer

Nothing to do with healthcare regardless of what plan it is, is truly zero anything.

Zero premium plans come with deductibles for several things including Rx, hospital stays, procedures etc...you are going to still have to pay something to use the plan. 

MA plans however, have generally been a good alternative to a Medicare Supplement for healthier individuals because if you don't take Rx, don't see a Dr., have no health issues, you don't have to cover the Medicare Supplement and Rx plan premiums which are both going up again on average 30% every year.

Steven Graves · Answer

That’s a great question, and it’s important to clarify. When we say a Medicare Advantage plan has a “zero premium,” we’re referring specifically to the fact that there’s no additional monthly premium for the plan itself beyond what you already pay for Medicare Part B.

However, “zero premium” doesn’t mean zero cost overall. These plans often come with out-of-pocket expenses such as:

Copayments for doctor visits, specialist appointments, or hospital stays

Coinsurance for certain services or procedures

Deductibles in some cases

Out-of-network charges if you go outside the plan’s provider network

Drug costs if the plan includes prescription coverage

Each plan also has an annual out-of-pocket maximum, which helps protect you financially, but you can still incur costs along the way—especially if you have complex or frequent healthcare needs.

So, while the monthly cost may be low or even $0, it’s important to look at the total cost of care based on how often you use healthcare services and which providers or medications you need.

This is why we always review not just premiums, but the full picture—so you can choose the plan that fits your health needs and budget.

Regards,

Medicare4USA.com
Serving all of Texas Florida and California
214-989-7900

Christopher Boyd · Answer

This is one of the most dishonest and most-misleading sayings in the business: "zero premium/zero co-pays". Unless an individual has some form of federal, state, local, or hospital financial assistance, he/she will have a co-pay and many circumstances such as chemotherapy, durable medical equipment, inpatient hospital care, ambulance, emergency room, urgent care, etc, co-pays can be quite high. For example, many Advantage Plans in my marketing area cover only 80% of Chemotherapy and Durable Medical Equipment, meaning the patient can be responsible for 20% of the cost until they reach the plan's annual maximum out of pocket (MOOP). The MOOP can range from $3000 to $13000 per year depending on network restrictions and plan allowances. I met a man once who had cancer and maxed out his MOOP of $6,700 two years in a row, and then nearly maxed out again in the third year, when he passed away. He and his family were very angry with the agent who signed him up and never explained the plan rules and restrictions.

Answered by Christopher Boyd on July 30, 2025

Agent Licensed in IN, KY, MI, OH, PA & TN

Answered by Christopher Boyd Medicare Insurance Agent

Edward Smith, ChFC, CRPS, AIF · Answer

I always use the example of pay now or pay later. With a Medicare Advantage plan you do not have a monthly premium as with a Medicare Supplement, but you do have co-pays and co-insurance cost if and when you use the plan. The max out of pocket with a Medicare Supplement Plan G for instance is the total of all monthly premiums plus the Part B deductible (currently $258 in 2025), where the out-of-pocket maximum with a Medicare advantage is going to be the co-pays and co-insurance amounts added together up to the maximum out of pocket or (MOOP) for the particular plan you have chosen.

Answered by Edward Smith, ChFC, CRPS, AIF on July 28, 2025

Broker Licensed in OH, GA, IN, KY & SC

Answered by Edward Smith, ChFC, CRPS, AIF Medicare Insurance Agent

Jonathan Potter · Answer

So the word premium refers to how much the plan will cost you every month. Generally they are zero or no premium plans but there are some that will cost anywhere from $33-100. This is the cost to subscribe in the plan.

Zero cost can refer to the plan premium but some people get that confused with the plan copays when you use the plan for doctor visits. If someone uses the term zero cost I would clarify if they are talking about the cost to be on the plan or the copays when you use the plan.

Mitch Anderson · Answer

The "cost" associated with a Medicare Advantage plan can come from the premium, copays, and coinsurance. It is important to understand the risk of cost and how they are similar and different from one Medicare Advantage plan to the next as they can very significantly.

Answered by Mitch Anderson on June 10, 2025

Agent Licensed in MN, IA & WI

Answered by Mitch Anderson Medicare Insurance Agent

Holt Rushing · Answer

Tell them that the cost of the plan is zero, but you still have copays. Tell them it takes care of the part A deductible, and 20% of part B, but it comes in forms of copays. Tell them it's privatized insurance.

Answered by Holt Rushing on June 18, 2025

Broker Licensed in MS, AK, AL & 29 other states

Answered by Holt Rushing Medicare Insurance Agent

Phillip Lovelady · Answer

My Daddy use to say, "Son, there ain't no such thing as a free lunch." This is the case with the zero dollar premium Medicare Advantage(MAPD.) In order to enroll in a MAPD, you have to be enrolled in Medicare A AND B, so you still have to pay your Part B premium. 

The Zero Premium does not mean "zero cost."  MAPD plans are a "Pay as you go" plan. Depending on what plan you enroll in you may  have co pays for Doctor visits, Specialist, and Hospital stays.

Rodney Powell · Answer

Some Advantage plans have a $-ZERO premium, but that doesn’t mean you pay nothing.

You’ll still have out-of-pocket costs like deductibles, copays, and coinsurance when you use services.

Sherry Rose · Answer

Zero Premium is the cost you pay for the plan unless you have a penalty related for not carrying a prescription drug plan.  I do not define a plan as zero cost since that could not be the case.

Steve Wilson · Answer

This is a great question and one that I carefully walk through to explain to my current and prospective clients.  Medicare Advantage plans MAY or MAY not have a premium and I always start with that foundation after I explain how the Medicare Part B premium works.  

If the plan has a premium of any amount ranging from $0 premium to anything beyond $0, it is almost certain that many costs will have copayments or sometimes other coinsurance.  The most common examples might be a specialist copay or a hospital admission copay.

There are some common "zero cost" items and those most commonly include (1) seeing your primary care physician for services, and (2) preventive care services.

I always take a very consultative approach so that the consumer has a really good understanding of how the plan works and this avoids any surprises.

Steven Bleicher · Answer

This question has more to do with your educational background than a full comprehension of Medicare. There can be a variety of premiums that are an integral part of a healthcare system. In effect, a premium is usually a monthly payment for a service provided. It can be a payment for a Medicare Supplement, or one for the Part D(rug) plan or one for a Hospital Indemnity plan. But “costs” are another entity. A cost could be a true “copay” at the pharmacy for an Rx prescribed by your doctor or a fee for a laboratory who will draw your blood based on an upcoming appointment with the doctor. So, costs are “indeterminate”, depending on any health checks/issues while premiums are definite costs that are common in the Medicare system.

Answered by Steven Bleicher on May 23, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Barbara Barnes, CMIP® · Answer

This can be complicated and difficult to understand for some people. I look at it two ways to try to make it make sense…

1. Just because YOU are not paying a premium, doesn’t mean a premium is not being paid by someone else. For $0 Premium Medicare Advantage plans, the ‘premium’ is being paid by the US Government. They don’t call it a premium, though. When you choose a Medicare Advantage plan, Medicare is no longer responsible for paying your claims. Instead, the insurance company that you chose for your Medicare Advantage insurance plan is responsible for paying your claims, according to your policy provisions and in accordance with Medicare guidelines. This frees up money in the Medicare system that the US Government uses to pay the insurance company offering the Medicare advantage plan. There is definitely a cost.

2. You may not be paying a premium, but you will pay for the services that you receive according to your plan’s contract. Depending on the plan, you will be responsible for copayments, deductibles and coinsurance, up to the plan’s maximum out-of-pocket provision. The maximum out-of-pocket requirement on your plan is an important number for you to know. That is the point within the plan year when you’ve paid the maximum amount that you are required to pay, and your insurance company will pay the rest for the remainder of the year. In Pennsylvania, this maximum can range from $4000-$9000 per person per year, depending on the plan. So even if you are not paying a premium, there will be a cost to receive medical care.

Before you buy a plan, it is important that you understand what you are buying and how it works. Please reach out to a professional Medicare insurance agent for assistance so that there are no surprises at the time of a claim.

DeeDee Whitlock · Answer

I go over every aspect of the coverage & explain EXACTLY how Medicare Advantage works & the fact that MD Anderson & Mayo usually does not accept these type plans. I would rather them know every detail before hand because I want clients in my office to hug my neck NOT ring it!!!

Answered by DeeDee Whitlock on June 23, 2025

Broker Licensed in LA

Answered by DeeDee Whitlock Medicare Insurance Agent

Rick Boyd · Answer

For many Medicare Advantage plans they come with a zero monthly premium, yet you still have to pay your Medicare part B premium. Advantage plans are a “pay as you go “ type plan wheee you pay co-pays or coinsurance for many if not most of the services. In essence, the more services you use in your Advantage plan, the more you pay.

Answered by Rick Boyd on July 28, 2025

Broker Licensed in KY, AZ, CA & OH, TN, TX & UT

Answered by Rick Boyd Medicare Insurance Agent

Paul Dzierzanowski · Answer

Quite simply, premiums and costs are two different things. A premium is something you pay, usually on a monthly basis, in order to have a Medicare Advantage plan. A cost is something you pay once you have established yourself as a member in a Medicare Advantage plan and obtain some type of service. If you need any more help on your specific situation don't hesitate to call me directly at 239-848-8893.

Answered by Paul Dzierzanowski on April 4, 2025

Agent Licensed in FL

Answered by Paul Dzierzanowski Medicare Insurance Agent

Christie Bondos · Answer

It's simple most people will pay the Part B Premium right out of their Social Security or receive a quarterly bill for $185.00. When reviewing a plan there are many copayments, deductibles, and coinsurances within the plan. IT must be reviewed in it's entirety!!

Answered by Christie Bondos on May 26, 2025

Broker Licensed in CT

Answered by Christie Bondos Medicare Insurance Agent

Heidi Delaney · Answer

Medicare Advantage plans may have a $0 premium, but this does not mean that you will not pay anything for services.  In place of an additional premium, you will have copays and coinsurance for the services you use.  

Some individuals with Medicaid may not have copays and coinsurance due to the state Medicaid program picking up the cost-share amounts for them.

Vachik Chakhbazian · Answer

A zero-premium Medicare Advantage plan means there's no monthly fee for the plan itself, but it's not necessarily "free" overall. You'll still have to pay your Medicare Part B premium, and you may also have out-of-pocket costs for services, medications, or other plan-specific expenses.

Answered by Vachik Chakhbazian on June 8, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Steve Brauer · Answer

Most Medicare Advantage plans do not have a monthly premium, but DO have copays for Medicare services. I tell people that Original Medicare is more of a "pre-pay" system, where Advantage plans are a "pay as you go" model.

Answered by Steve Brauer on April 13, 2025

Broker Licensed in AZ & CA

Answered by Steve Brauer Medicare Insurance Agent

Marcie Barnes · Answer

When I explain a Medicare Advantage plan that has a $0 premium.  I explain that although your premium is $0, you will have a cost share on services.

Carol Thompson · Answer

There may be no premium cost with most plans however there is Part B cost. 

Part B stands for outpatient services such as bloodwork, dr. visits, imaging and many more that may require co-payments or co-Insurance.

Rodolfo Rojas · Answer

Zero premium for a specific plan is just for the cost of the plan that you have chosen. 
The plan has charges for specific services. For example, your primary visits, most likely are zero and the specialist may be $25.00
It just depends on the plan that you have chosen. 
Some plans may cost you a certain amount, but it may have fewer charges for a specific service.

Andre Cabral · Answer

Federal government funds private companies to assist their members and, depending on the plan, it may have a $0 monthly premium. However it doesn't mean $0 cost, for there are co-pays and deductibles, though limited by an annual Maximum out-of-pocket.

Answered by Andre Cabral on May 12, 2025

Agent Licensed in NJ

Answered by Andre Cabral Medicare Insurance Agent

Larry Pereiro · Answer

Medicare Advantage plans different by carrier. "zero-premium" simply means that the carrier does not charge a premium for the coverage. There may be some benefits that also have zero cost share while other benefits can have co-pays and co-insurance until the maximum out of pocket limit has been reached.

Answered by Larry Pereiro on June 2, 2025

Agent Licensed in IN

Answered by Larry Pereiro Medicare Insurance Agent

Judi Norton · Answer

Zero Premium needs to say Zero MONTHLY Premium. Zero cost with a Medicare Advantage Plan is misleading and many clients are concerned about their finances and any word Zero needs to be explained further.

Answered by Judi Norton on April 14, 2025

Agent Licensed in NM

Answered by Judi Norton Medicare Insurance Agent

Brianna Douros · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/how-do-you-explain-to-clients-that-zero-premium-doesnt-mean-zero-cost-with-medicare-advantage#brianna-douros

Ellen Diehl · Answer

Advantage plans are "managing" your care for their profit.  I only sell Supplement plans that allow you to go to any Dr. in the USA USA USA that accepts Original Medicare Part A & B.

Babs Atwell · Answer

I explain to all our clients that a Medicare advantage plan typically has no extra monthly premium beyond their part b premium. However there are some exceptions to that as well. Rather than an extra monthly premium, they will typically have copays with a Medicare Advantage plan. Those copays vary depending on the specific plan they would choose. Whereas with a Medicare supplement plan, they would typically have an extra monthly premium beyond their part b premium. However, with a Medicare supplement plan, they MAY have less out of pocket expenses for copays and doctor visits depending on their use. This is why we always recommend a personalized consultation with a trusted local/agent broker to discuss your specific needs.

Answered by Babs Atwell on May 1, 2025

Broker Licensed in OH

Answered by Babs Atwell Medicare Insurance Agent

Tanja Roulhac · Answer

What "Zero-Premium" Means
A zero-premium Medicare Advantage plan means you do not have to pay a monthly premium for the plan itself.

However, this does not mean you won’t have to pay any other costs.

What You Still May Have to Pay
Copayments or coinsurance for doctor visits, specialist visits, hospital stays, and other services.

Deductibles before coverage starts for some services or drugs.

Costs for services not covered by the plan.

Premium for Medicare Part B, which you must keep paying even if your Medicare Advantage plan has no premium.

Important to Remember
Think of zero-premium as just one piece of the total cost puzzle. While it can help reduce your monthly out-of-pocket spending, you’ll likely still pay when using healthcare services.

Jim Carroll · Answer

Blunt but honest; sometimes you really do get what you pay for. Insurance companies are businesses, and receive a monthly payment from the Centers for Medicare & Medicaid Services. They would go out of business if they paid 100% of everything. That's why there's a give and take.

I tell my clients to think about a double-sided scale, like Statue of Justice holds. Imagine your monthly premiums are in one scale and the other side is empty. Your premiums make the scale go down. Then, put everything else you have to pay (deductible, 20% coinsurance, and maximum out-of-pocket) on the other side. What happens? The more you add to one side, it goes down and the other side goes up.

Unfortunately, people look at the immediate benefit of not having a monthly premium and don't weigh the extra costs of the plan that are shown in the Summary of Benefits. This is why a needs assessment is so important. Deciding whether to enroll in a Medicare Advantage plan or a Medicare Supplement depends on you health and how much you will spend on medical care for the entire year.

Medicare Advantage Plan (average costs for easy math)
Monthly Premium:   $0
Part B Premium (what comes out of your monthly Social Security check): $185x12= $2,200
Annual Deductible:  $5,000
Coinsurance:  20% until you reach your Maximum Out-of-Pocket
Maximum Out-of-Pocket:  $9,400
Dr. copays, 2 visits per year:   $50
2 Specialist, 2 visits each per year:  $200

TOTAL..................................................$7,470 (this is only factoring the Deductible and not Coinsurance to reach your Maximum OOP)

VS.

Medicare Supplement Plan G
Monthly Premium:   $200x12= $2,400
Part B Premium (what comes out of your monthly Social Security check): $185x12= $2,200
Annual Deductible:  $257
Maximum Out-of-Pocket:  $0
Dr. copays, 2 visits per year:   $0
2 Specialist, 2 visits each per year:  $0

TOTAL..................................................$4,857

Adriane Williams · Answer

Zero premium means the plan doesn’t have a monthly cost. That doesn’t eliminate costs plan share or the cost to do business with other providers.

How do you explain to clients that "zero-premium" doesn't mean "zero-cost" with Medicare Advantage?

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How do you explain to clients that "zero-premium" doesn't mean "zero-cost" with Medicare Advantage?

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