What is it?
Medicare Part B is the medical insurance portion of Medicare.Part B covers physician services, outpatient hospital care, and many other services typically covered under health insurance plans. Part B is financed through monthly premiums paid by covered beneficiaries and by contributions from the Federal government.
What is the cost to beneficiaries?
In 2011, there are three "standard" premium levels for individuals with a modified adjusted gross income (MAGI) of $85,000 or less and joint filers with $170,000 or less. MAGI is the total of your adjusted gross income and tax-exempt interest income. The standard premiums for 2011 are:
- $115.40 for those who become effective in 2011 or who do not currently draw a Social Security check;
- $110.50 for those who became effective during 2010;
- $96.40 for those who became effective prior to January 1, 2010.
The premium is indexed for inflation, and typically increases each year. However, there is a "hold-harmless" clause which states that if there is not a cost of living increase for Social Security benefit payments, your Part B premium is frozen at your current level.
Your monthly premium will be higher if you file an individual income tax return and your modified adjusted gross income (MAGI) is more than $85,000, or if you file a joint income tax return and your MAGI is more than $170,000.
The Medicare Part B deductible is $162 in 2011.
What does Medicare Part B cover?
Medical care that is not inpatient is usually covered under Medicare Part B. Medicare Part B covers 80 percent of most medically necessary physician or outpatient charges, including charges from a physician for care received in a hospital.
Services covered under Medicare Part B include:
- Ambulance Services
- Ambulatory Surgical Centers
- Blood (the first 3 units of blood are not covered unless you have the blood donated by you or someone else)
- Cardiac Rehabilitation
- Chiropractic Services (limited)
- Clinical Laboratory Services
- Clinical Research Studies
- Defibrillator (Implantable Automatic)
- Diabetes Supplies (note: insulin and certain medical supplies used to inject insulin, such as syringes, and some oral diabetic drugs may be covered by Medicare Prescription Drug coverage, Part D)
- Doctor Services
- Durable Medical Equipment (like walkers) -- see Caution note regarding specific suppliers for certain states that began 1/1/2011
- EKG Screening
- Emergency Department Services
- Eyeglasses (one pair of eyeglasses with standard frames or one set of contact lenses after cataract surgery that implants an intraocular lens)
- Federally-Qualified Health Center Services
- Foot Exams and Treatment (if you have diabetes-related nerve damage and/or meet certain conditions)
- Hearing and Balance Exams (if your doctor orders these tests to see if you need medical treatment. Hearing aids and exams for fitting hearing aids are not covered)
- Home Health Services (covers only medically necessary services; you pay nothing)
- Kidney Dialysis Services and Supplies
- Kidney Disease Education Services
- Mental Health Care (you pay 20% of the medicare-approved amount for a visit to a doctor or other health care provider to diagnose your condition; you pay 45% for treatment of your condition - see Tip for changes in coinsurance in future years)
- Non-doctor Services (such as physician assistants, nurse practitioners, social workers, physical therapists, and psychologists)
- Occupational Therapy
- Outpatient Medical and Surgical Services and Supplies
- Physical Therapy (there may be limits on these services and exceptions)
- Prescription Drugs (limited number of drugs such as injections you get in a doctor's office, certain oral cancer drugs, drugs used with some types of durable medical equipment, such as a nebulizer or external infusion pump)
- Prosthetic/Orthotic Items
- Pulmonary Rehabilitation
- Rural Health Clinic Services
- Second Surgical Opinions (in some cases, Medicare covers third surgical opinions)
- Smoking Cessation (not part of the new preventive care services)
- Speech-Language Pathology Services
- Surgical Dressing Services
- Tests (other than lab tests, such as x-rays, MRIs, CT scans, EKGs, and some other diagnostic tests)
- Transplants and Immunosuppressive Drugs
- Travel (health care needed when traveling outside the U.S. -- rare cases such as in an emergency and a foreign hospital is closer than a U.S. hospital)
- Urgently-Needed Care
Caution for Durable Medical Equipment: Effective January 1, 2011, you must use specific suppliers for Medicare to pay for most durable medical equipment if you live in or travel to certain areas of the following states: California, Florida, Indiana, Kansas, Kentucky, Missouri, North Carolina, Ohio, Pennsylvania, South Carolina, and Texas. To locate covered providers, visit www.medicare.gov/supplier or call 1-800-MEDICARE (1-800-633-4227); TTY 1-877-486-2048.
Caution: Medicare regulations specifying what it will cover almost always begin with a general rule, followed by exceptions. If you are denied coverage, it is always wise to look into whether or not you can meet one of the exceptions.
Tip: Mental Health Care coinsurance paid by you will decrease to 40% in 2012; 35% in 2013; and finally to 20% in 2014 to match most other Part B services.
Services excluded from Medicare Part B coverage
In general, Medicare pays only for services it considers reasonable or medically necessary. Specific exclusions include:
- Cosmetic surgery, unless particular medical conditions render it necessary
- Procedures considered experimental--for example, heart transplants were not covered by Medicare until 1986
- Hearing aids and fittings
- Chiropractic services, except for treatment of subluxation (partial dislocation) of the spine
- Most eyeglasses and eye exams (except following cataract surgery that implants an intraocular lens)
- Most dentures and dental care
- Prescription drugs you administer yourself, such as those you buy at a drug store and take at home (exceptions are immunosuppressive drugs and anti-rejection drugs for kidney transplant patients)
- Over-the-counter drugs
- Care outside of the United States (except when a Mexican or Canadian hospital is closer, such as in an emergency, even though you reside in the United States, or if you require care while traveling through Canada en route to Alaska)
Tip: Prescription drug coverage is available under Medicare Part D (prescription drug coverage). For more information on this benefit and other changes to Medicare, see The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 at www.medicare.gov or click the "Part D" tab above.
NEW FOR 2011. As part of the Affordable Care Act of 2010, Medicare now pays for most preventive services at no cost to you (no Part B deductible or coinsurance) if you get the services from a doctor or other health care provider who accepts Medicare assignment.
What Preventive Services are covered under Part B?
- Abdominal Aortic Aneurysm Screen (one-time ultrasound for people at risk. You must get a referral as part of your one-time "Welcome to Medicare" physical exam).
- Bone Mass Measurement/Bone Density (once every 24 months for people who have certain medical conditions or meet certain criteria)
- Cardiovascular Screenings (every 5 years to test your cholesterol, lipid, and triglyceride levels)
- Colorectal Cancer Screening - Fecal Occult Blood Test (once every 12 months if age 50 or older)
- Colorectal Cancer Screening - Flexible Sigmoidoscopy (generally, once every 4 years, or every 10 years when used instead of a colonoscopy for those not at high risk if age 50+)
- Colorectal Cancer Screening - Colonoscopy (generally, once every 10 years, or every 24 months if high risk, or 4 years after a previous flexible sigmoidoscopy)
- Colorectal Cancer Screening - Barium Enema (once every 4 years instead of a sigmoidoscopy or colonoscopy if age 50+; once every 24 months instead of a colonoscopy for high risk)
- Diabetes Screenings (covered if you have certain risk factors - ask your doctor)
- Diabetes Self-Management Training (for people with diabetes with a written order from a doctor or other health care professional)
- Flu shot (one per flu season)
- Glaucoma Tests (once every 12 months for those at high risk)
- Hepatitis B Shots (covered for people at high or medium risk)
- HIV Screening (covered for people at any age who ask for the test, pregnant women [up to 3 times during pregnancy], and people at increased risk for the infection)
- Mammograms - Screening (once every 12 months for women age 40+. One baseline mammogram for women between 35 - 39)
- Medical Nutrition Therapy Services (if you have diabetes or kidney disease, or you have had a kidney transplant in the last 3 years, and your doctor refers you for the service)
- Pap Tests and Pelvic Exams, including clinical breast exam (once every 24 months, or once every 12 months for women at high risk)
- Physical Exam - "Welcome to Medicare" (one-time review of your health, education, and counseling about preventive services and referrals for other care if needed. Covered within the first 12 months of your Part B effective date)
- Physical Exam - Yearly "Wellness" Exam (covered once every 12 months if you have had Part B for longer than 12 months, a yearly wellness visit to develop or update a personalized preventive plan based on your current health and risk factors)
- Pneumococcal Shot (covered once in your lifetime)
- Prostate Cancer Screenings (digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for men over age 50)
- Smoking Cessation (up to 8 visits during a 12 month period if you haven't been diagnosed with an illness caused or complicated by tobacco use)
Tip: Obtain your preventive "screening" tests as part of your physical exam so you do not have to pay a deductible and/or coinsurance that applies to diagnostic physician office visits.
Tip: If you are covered by a Medicare Advantage plan (Part C), check with your plan to see how preventive services are covered.
Caution: Your first yearly "Wellness" exam can't take place within 12 months of your "Welcome to Medicare" physical exam.
You can get further information about coverage under Medicare Part B by calling the Medicare Helpline at 1-800-MEDICARE (1-800-633-4227) (English and Spanish) TTY 1-877-486-2048.
Citation: Medicare & You, cms.gov, medicare.gov