Medicare Part B
Riddled as it is with myriad financial nuances, coverage conditions, and four different “parts,” the process of navigating the Medicare bureaucracy may sound daunting, especially if this is your first time dealing with it. But the benefits of understanding the system can help participants get the best care possible—and save a significant amount of money. And when it comes to Medicare Part B, which received a significant overhaul in 2011 that benefits scores of older Americans, it’s critical to understand the scope of what is and isn’t covered.
In short, Medicare Part B is the Medicare program that covers doctor bills and other outpatient costs. It’s one of Medicare’s four programs, each identified by a letter: Part A (hospital insurance), Part B (medical insurance), Part C (managed care plans), and Part D (prescription drug coverage).
Almost everyone who is 65 and older is eligible for Medicare Part B. Although it will pay part of many participants’ doctor bills and other outpatient costs, it leaves some services uncovered and pays only a portion of those services that it does cover. Participants may need to fill the gaps in coverage—the costs Part B doesn’t pay—with Medigap supplemental insurance, a Part C managed care plan, Medicaid benefits or other sources.
Below, we’ve highlighted what you should know about Medicare Part B coverage and enrollment details for you or a loved one.
Medicare Part B Explained
Any U.S. citizen or legal resident who’s been in the country for five consecutive years is eligible to enroll in Medicare Part B. What’s more, participants aren’t required to have Medicare Part A in order to enroll in Part B.
Every individual enrolled in Medicare Part B pays a monthly premium for it (except for people enrolled in Medicaid, which pays the Medicare Part B premium for them). The premium goes up each year on January 1. In 2020, most people will pay $144.60 per person, per month. Single people (or a married person filing a separate tax return) with an adjusted gross income over $87,000 per year pay higher premiums, as do couples whose combined income exceeds $174,000, according to the following schedule:
|Single/Married Yearly Income||Monthly premium per person|
|Over the above amounts and up to $109,000/$218,000||$202.40|
|Over the above amounts and up to $136,000/$272,000||$289.20|
|Over the above amounts and up to $163,000/$326,000||$376|
|Over the above amounts but less than $500,000/$750,000||$462.70|
Medicare bases these calculations on tax returns from two years before. If for any reason participants’ actual income has dropped significantly in the last two years, they can contact Medicare with this information and request that their premiums be adjusted accordingly.
For those who don’t enroll in Part B when first eligible for it at age 65 but do enroll later, the premiums will be 10 percent higher for every year of delay in enrollment.
Does Part B cover doctor bills?
The short answer is yes, as doctor bills are probably the biggest chunk of outpatient expenses that are covered by Part B. The category includes any service by a doctor wherever it’s provided—hospital, doctor’s office, clinic, etc. It also covers any other work performed by the doctor’s staff, as well as any drugs administered in the office.
That being said, the two basic coverage rules are that care must be medically necessary, and it must be performed by a doctor who accepts Medicare payment. This means that before participants see any new doctor, they must make sure that the doctor accepts Medicare.
With many limitations, Part B also covers some care by a chiropractor. This is only for medically necessary short-term manipulation of out-of-place vertebrae—neck and back—by a Medicare-certified chiropractor or another qualified provider. Before seeing a chiropractor, have the chiropractor’s office check directly with Medicare to ensure coverage. Medicare does not cover x-rays, massage therapy, and acupuncture ordered by a chiropractor.
What is Part B coverage for other outpatient care?
In addition to doctor bills, Part B covers many other types of outpatient care. This includes care at an emergency room or clinic, X-rays, and laboratory work. Ambulance service is also covered, in an emergency, to the closest medical facility that can provide you with the appropriate level of care. In non-emergency but medically necessary situations—such as transportation to a dialysis facility for patients with end-stage renal disease—requires a written order from a doctor for Medicare to consider payment.
Part B covers medical equipment and supplies, including splints, braces, bandages, prosthetics and orthotics, walkers, and remedial shoes. It also includes equipment such as glucose monitors and infusion pumps, ventilators, oxygen and oxygen equipment, and pacemakers, as well as wheelchairs and hospital beds. For any of this to be covered, however, it must be prescribed by a doctor.
Part B also covers physical therapy, occupational therapy, and speech-language pathology services if prescribed and regularly reviewed by a doctor. The therapist or facility providing the care must be Medicare-certified. How much Medicare pays for this care is determined by where the care is provided.
A variety of other services are covered by Part B, including advance care planning, integrated behavioral health services, blood transfusion processing and handling, cardiac rehabilitation, chemotherapy, chronic condition management services, clinical research studies, CPAP therapy, defibrillator implantation, emergency department services, EKG/ECG screening, post-cataract surgery eyeglasses, foot care for diabetes and other conditions, dialysis services and supplies, laboratory services, outpatient mental health care, opioid use disorder treatment services, outpatient hospital services, pulmonary rehabilitation, second opinions for surgery, certain vaccines, diagnostic testing, telehealth services, physician services for organ transplants, immunosuppressive drugs, urgent care, and health care when traveling outside of the United States.
Does Part B cover preventive screening examinations?
From its beginnings, Medicare coverage has been biased against preventive medicine—for example, the most basic preventive tool, the regular annual physical, hasn’t been covered. But over the past several years Part B has been expanding to include a number a of preventive procedures, including several types of free screenings (diabetes, cardiovascular disease, HIV, breast cancer, cervical cancer, colorectal cancer, alcohol misuse, depression, obesity, and more), flu shots, smoking cessation, and annual wellness visits. During your first 12 months of Part B enrollment, you are eligible for a “Welcome to Medicare” preventative visit that includes certain screenings and vaccinations, a review of your medical and social history, and referrals for additional care. For a complete list of preventative procedures covered by Part B, visit this page at Medicare.Gov.
Does Part B cover home healthcare?
Part B covers a limited amount of home healthcare, under certain circumstances. But it’s important to understand that Part B does not cover long-term home care, or care that consists only of non-medical help (such as help with walking, bathing, eating, dressing).
Home care is covered by Part B only if a participant is confined to home and needs part-time skilled nursing care or physical therapy, occupational therapy, or speech-language pathology services. If someone qualifies for this skilled care, Part B can also cover some non-medical help from a part-time aide, as well as medical supplies and equipment. Care must be ordered by a doctor and provided by a Medicare-certified home health agency; individual caregivers aren’t covered.
Unlike home care rules under Medicare Part A, Part B home care doesn’t require that participants first have had a minimum three-day hospital stay.
What important medical care doesn’t Part B cover?
Although Part B covers most kinds of outpatient care, there are a few important exceptions. The first is frequent routine physical exams; Medicare Part B covers an initial wellness physical exam within the first 12 months of enrolling, and after that one wellness physical exam per year, but not more frequent routine physicals.
Part B covers only care that is medically necessary, which Medicare interprets as excluding most chiropractic and other types of alternative care, such as massage, acupuncture, acupressure, and homeopathy. It also excludes elective or cosmetic surgery or other treatments. Similarly, Part B doesn’t cover vaccinations or immunizations, such as those people take when they travel abroad. However, Medicare Part B does cover the full cost of pneumonia, hepatitis B, and flu shots.
Nor is there any Part B coverage for routine eye or hearing exams, and none for hearing aids, eyeglasses, or contact lenses (except following cataract surgery). Treatment for diseases of the eye or ear, however, can be covered if provided by a medical doctor. Dental work is not covered.
Finally, Part B doesn’t cover any drugs, prescription or otherwise, that participants take at home. Instead, prescription medication can be partially covered by a Medicare Part D insurance policy.
How much does Part B pay?
For each type of Medicare-covered care, Medicare approves only a specific amount, called an approved charge, of which Part B may pay all or only a portion, depending on the type of service.
|Doctors visits||80 percent of bills|
|Laboratory costs||100% of laboratory, X-ray, and other diagnostic charges|
|Home healthcare||100% of agency charges; 80% for medical equipment from the agency|
|Outpatient therapy||The amount Part B pays for physical therapy, occupational therapy and speech-language pathology depends on where a participant receives it. If it’s given at home, as part of Medicare-approved home healthcare, Part B pays 100%; at a hospital outpatient department, 100 percent, at a doctor’s or therapist’s office, 80%.|
|Flu, hepatitis B, and pneumonia vaccination||100%|
|Outpatient mental healthcare||50%, regardless of who provides it|
What Part B-covered costs do participants have to pay?
In addition to their monthly premium, participants are likely to be responsible for a large portion of their doctor and other outpatient medical bills, despite Part B coverage. Why is this? First, there’s a yearly deductible ($198) each participant has to pay before Medicare will pay anything. Also, when Part B pays only part (usually 80 percent) of an approved charge, participants are personally responsible for the unpaid remainder.
Participants may also be responsible for the difference between the Medicare-approved amount and what the doctor or another provider actually charges. By law, this can’t exceed 15 percent more than the approved charge, which is called the limiting charge.
Whether someone is charged this extra 15 percent depends on whether the doctor or other provider accepts “assignment.” This means the provider accepts the Medicare-approved charge as the entire amount of the bill. Most doctors accept assignment of Medicare charges—but not all will do so, and many outpatient clinics do not. So participants need to check on their doctor’s or provider’s policy about assignment before beginning any care. To fill the unpaid gaps in Part B coverage and payment, participants may want to buy a Medigap insurance policy. Or, if they have low income and few assets, they can look to Medicaid or other programs for low-income seniors for help paying these bills.
How do participants enroll in Part B?
If they’re already receiving any type of Social Security, Railroad Retirement, or federal civil service retirement system benefit when they turn 65, they’ll automatically be enrolled in Medicare Part B. Medicare will send a membership card and information packet two to three months before they turn 65. Their premiums will be automatically deducted from their monthly Social Security or other government benefits check. If they don’t want to be enrolled in Medicare Part B, they can notify Medicare on a form included in the packet.
Those who aren’t automatically enrolled in Medicare Part B can enroll as early as three months before their 65th birthday, with coverage beginning when they turn 65. They can enroll at any local Social Security office.
Where can I find more information?
Medicare’s website has information about Part B eligibility, coverage, and enrollment. You can also call Medicare’s toll-free phone number, 800-MEDICARE (800-633-4227). Part B’s day-to-day operations, however, are handled by large private insurance companies called Medicare Part B “carriers.”
Different health insurance carriers handle Part B in different regions of the country. If you have a question or complaint about a particular decision regarding someone’s Part B coverage, contact the carrier directly. You can find the name and contact information for their carrier in the upper right-hand corner of the Medicare Summary Notice explaining the decision, which the carrier will have mailed to the participant. Or you can get the contact information from the Medicare website.
Medicare Part B Coverage for Regular Exams & Screenings
Medicare covers a considerable amount of preventive medicine and a number of important screening tests, paying 100 percent of the cost if you or the person you’re caring for meets certain conditions. If you know what these tests are, you can make sure to ask your doctor to order the test whenever it’s appropriate.
1. Comprehensive wellness exam
Medicare covers one general wellness exam, called an initial “Welcome to Medicare” preventative visit within twelve months of the date a person first enrolls in Part B. This exam includes a comprehensive health risk assessment, which includes both a physical and a cognitive impairment assessment. Participants should notify their primary care doctor’s office when they first enroll in Medicare Part B to schedule this exam. Thereafter, anyone enrolled in Medicare Part B is entitled to one such wellness exam every year.
2. Colorectal cancer screening
Colorectal cancer is a deadly disease that becomes more common as people age. Screening for this cancer is done through several screenings, which can be time-consuming and expensive. As a result, they aren’t regularly scheduled and must be specially ordered by an older adult’s doctor. Medicare Part B will pay for a screening test if the person’s doctor orders it based on medically accepted risk factors. Even without any specific risk factors, most doctors will order these screenings—and Medicare will pay for them—between every two and ten years depending on risk factors for people age 50 and over. However, for a screening colonoscopy, there is no minimum age requirement.
3. A pelvic exam and Pap smear for older women
Medicare Part B covers a pelvic exam and Pap smear for a woman once every three years. If she has any personal or family medical history that places her at higher risk for cervical cancer or other pelvic diseases, Medicare will cover the exam every year if her doctor provides Medicare with the reason (meaning the risk factor) when submitting the bill to Medicare. She doesn’t need to do anything except remind the doctor to schedule the exam for her. Medicare pays the full amount of this exam even if she hasn’t yet met her Medicare Part B yearly deductible.
4. A yearly mammogram for women
Every woman who qualifies for Medicare is entitled to a yearly mammogram covered by Medicare Part B. Medicare pays the full amount even if she hasn’t yet paid her yearly Part B deductible. If she has the mammogram at a clinic or facility without a doctor’s prescription, she has to make sure that the facility participates in Medicare so that Medicare will pay and the facility will accept Medicare’s payment as payment in full.
5. A bone density test for women
Women are at much greater risk than men for osteoporosis, a decrease in bone mass that makes the bones fragile and easily broken. The likelihood that a woman will develop the disease increases with her age. If she has been identified by her doctor as being at high risk for osteoporosis, Medicare Part B will pay for a bone density test for her every two years.
6. A yearly prostate cancer screening for men
Prostate cancer is a deadly disease that may exhibit no physical symptoms in its early stages. Luckily, initial screening tests for prostate cancer are simple and inexpensive. Medicare Part B will pay for each man to have an annual screening, as well as any follow-up tests if medically indicated.
7. Diabetes screening as needed
If an older adult’s doctor says he or she is at risk for diabetes—because of being overweight, having a family history of diabetes, or other risk factors—Medicare Part B will pay for a regular screening test for the disease.
8. A yearly glaucoma test
Glaucoma is a serious eye disease that can cause blindness. There are recommended screening tests to spot glaucoma, and Medicare Part B pays for one such test each year.