Medicare Part B - Medical Insurance & Doctors Visits
What is Medicare Part B?
Medicare Part B is a health insurance program administered by the federal government which primarily helps cover non-hospital medical needs including doctor services, outpatient care, lab work, ambulance, and medical equipment costs. Part A and Part B are also known as “Original Medicare”.
Who is eligible for Part B?
In general, people 65 or older are eligible for Part B. Younger people with certain disabilities can also be eligible for Part B
If you are 65 or older, you are eligible for Part B if:
- You currently receive retirement benefits from Social Security or the Railroad Retirement Board.
- You are currently eligible for Social Security or the Railroad Retirement Board benefits but you haven’t applied for them yet.
If you are under 65, you are eligible for Part B if:
- You have received Social Security or the Railroad Retirement Board disability benefits for 24 continuous months
- You have End-Stage Renal Disease (ESRD) and meet certain criteria.
Typically you have to be eligible for Part A in order to be eligible for Part B. People are usually not automatically enrolled as Part B is a voluntary program.
What does Part B cover?
Part B helps cover doctor visits, medical supplies, and other services considered medically necessary to treat your condition. Medical services covered include:
What is covered - clinical research studies, which test different types of medical care, like how well a cancer drug works. These studies help doctors and researchers see if a new treatment works and it's safe. Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover some costs, like office visits and tests, and in certain qualifying clinical research studies.
What is covered - ambulance services to or from a hospital, critical access hospital (CAH), or skilled nursing facility (SNF). Medicare covers and helps pay for ambulance services only when other transportation could endanger your health, like if you have a health condition that requires this type of transportation.
What is covered - medically necessary durable medical equipment (DME) that your doctor prescribes for use in your home. Only your doctor can prescribe medical equipment for you. DME meets these criteria:
- Durable (can withstand repeated use)
- Used for a medical reason
- Not usually useful to someone who isn't sick or injured
- Used in your home
- Has an expected lifetime of at least 3 years
DME that Medicare covers includes, but isn't limited to:
- Air-fluidized beds and other support surfaces (these supplies are only rented)
- Blood sugar monitors
- Blood sugar (glucose) test strips
- Canes (however, white canes for the blind aren't covered)
- Commode chairs
- Continuous passive motion (CPM) machine
- Hospital beds
- Infusion pumps and supplies (when necessary to administer certain drugs)
- Manual wheelchairs and power mobility devices
- Nebulizers and nebulizer medications
- Oxygen equipment and accessories
- Patient lifts
- Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
- Suction pumps
- Traction equipment
What is covered - mental health services and visits with these types of health professionals:
- Psychiatrist or other doctor
- Clinical psychologist
- Clinical social worker
- Clinical nurse specialist
- Nurse practitioner
- Physician assistant
Medicare only covers these visits, often called counseling or therapy, when they’re provided by a health care provider who accepts assignment. This means there is an agreement by your provider to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.
Part B covers outpatient mental health services, including services that are usually provided outside a hospital, like in these settings:
- A doctor’s or other health care provider's office
- A hospital outpatient department
- A community mental health center
- Part B also covers outpatient mental health services for treatment of inappropriate alcohol and drug use.
Part B helps pay for these covered outpatient services:
- One depression screening per year. The screening must be done in a primary care doctor’s office or primary care clinic that can provide follow-up treatment and referrals.
- Individual and group psychotherapy with doctors or certain other licensed professionals allowed by the state where you get the services.
- Family counseling, if the main purpose is to help with your treatment.
- Testing to find out if you’re getting the services you need and if your current treatment is helping you.
- Psychiatric evaluation.
- Medication management.
- Certain prescription drugs that aren’t usually “self administered”(drugs you would normally take on your own), like some injections.
- Diagnostic tests.
- Partial hospitalization.
- A one-time “Welcome to Medicare” preventive visit. This visit includes a review of your potential risk factors for depression.
- A yearly “Wellness” visit. This is a good time to talk to your doctor or other health care provider about changes in your mental health so they can evaluate your changes year to year.
What is covered - Medicare Part B (Medical Insurance) covers partial hospitalization in some cases. Partial hospitalization provides a structured program of outpatient psychiatric services as an alternative to inpatient psychiatric care. It’s more intense than care you get in a doctor’s or therapist’s office. This treatment is provided during the day and doesn’t require an overnight stay. Medicare helps cover partial hospitalization services when they’re provided through a hospital outpatient department or community mental health center. Along with your partial hospitalization program, Medicare may cover occupational therapy that’s part of your mental health treatment and/or individual patient training and education about your condition.
Medicare only covers partial hospitalization if the doctor and the partial hospitalization program accept assignment.
What is not covered -
- Transportation to or from mental health care services
- Support groups that bring people together to talk and socialize. (This is different from group psychotherapy, which is covered.)
- Testing or training for job skills that isn't part of your mental health treatment.
What is covered - a second opinion in some cases for surgery that isn’t an emergency. Medicare also will help pay for a third opinion if the first and second opinions are different.
What is covered - Medicare Part B (Medical Insurance) generally doesn't cover most prescription drugs used at home, but it does cover a limited number of outpatient prescription drugs under limited conditions. Generally, drugs covered under Part B are drugs you wouldn't usually give to yourself, like those you get at a doctor's office or hospital outpatient setting. Drugs not covered under Part B may be covered under Medicare prescription drug coverage (Part D). If you have Part D, check your plan's formulary to see what outpatient drugs are covered.
Examples of drugs covered by Part B:
- Drugs used with an item of durable medical equipment: Medicare covers drugs infused through an item of durable medical equipment, like an infusion pump or drugs given by a nebulizer.
- Some antigens: Medicare helps pay for antigens if they're prepared by a doctor and given by a properly instructed person (who could be the patient) under appropriate supervision.
- Injectable osteoporosis drugs: Medicare helps pay for an injectable drug for women with osteoporosis who meet the criteria for the Medicare home health benefit and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis. A doctor must certify that the woman is unable to learn how to or unable to give herself the drug by injection. The home health nurse or aide won't be covered to provide the injection unless family and/or caregivers are unable or unwilling to give the woman the drug by injection.
- Erythropoisis–stimulating agents: Medicare helps pay for erythropoietin by injection if you have End-Stage Renal Disease (ESRD) or need this drug to treat anemia related to certain other conditions.
- Blood clotting factors: If you have hemophilia, Medicare helps pay for clotting factors you give yourself by injection.
- Injectable and infused drugs: Medicare covers most injectable and infused drugs given by a licensed medical provider.
- Oral End-Stage Renal Disease (ESRD) drugs: Medicare helps pay for some oral ESRD drugs if the same drug is available in injectable form and covered under the Part B ESRD benefit.
- Parenteral and enteral nutrition (intravenous and tube feeding): Medicare helps pay for certain nutrients for people who can't absorb nutrition through their intestinal tracts or can't take food by mouth.
- Intravenous Immune Globulin (IVIG) provided in the home: Medicare helps pay for IVIG for people with a diagnosis of primary immune deficiency disease. A doctor must decide that it's medically appropriate for the IVIG to be given in the patient's home. Part B covers the IVIG itself, but Part B doesn't pay for other items and services related to the patient getting the IVIG in his or her home.
- Flu shots
- Pneumococcal shots
- Hepatitis B shots
- Other shots: Medicare helps pay for some other vaccines when they're directly related to the treatment of an injury or illness.
- Transplant drugs (also called immunosuppressive drugs): Medicare covers transplant drug therapy if Medicare helped pay for your organ transplant. (Part D may cover other transplant drugs not covered by Part B, even if Medicare didn't pay for the transplant. If you have ESRD and Original Medicare, you may join a Medicare drug plan.)
- If you're entitled to Medicare only because of permanent kidney failure, your Medicare coverage will end 36 months after the month of the transplant. Medicare won't pay for any services or items, including transplant drugs, for patients who aren't entitled to Medicare.
- Medicare will continue to pay for your transplant drugs with no time limit if you meet either of these conditions:
- You were already entitled to Medicare because of age or disability before you got ESRD.
- You became entitled to Medicare because of age or disability after getting a transplant that was paid for by Medicare, or paid for by private insurance that paid primary to your Medicare Part A (Hospital Insurance) coverage, in a Medicare-certified facility.
Is there a monthly premium cost for Part B?
Yes, the standard monthly premium amount for Part B in 2021 is $148.50, but this can be greater if you have a high income.
If you receive Social Security, Railroad Retirement Board, or Office of Personnel Management benefits, your Part B premium will be automatically deducted from your benefit payment.
What are the out-of-pocket costs (deductible, coinsurance) for Part B?
Part B has a $203 annual deductible. After you reach the deductible level, you will typically pay a 20% coinsurance of the approved amount for Medicare Part B services.
When can I sign up for Part B?
There is a 7 month initial enrollment period for Part B. You can enroll starting 3 months before the month you turn 65, during the month you turn 65, and 3 months after your birthday month. Other enrollment time periods apply if you are eligible due to disability or ESRD.
Is there a penalty for signing up late for Part B?
Yes, you will usually have to pay a late enrollment penalty if you do not sign up for Part B when you are first eligible. The penalty may cause your Part B monthly premium to go up 10% for each 12 month period you could have had Part B but did not sign up. The penalty usually does not apply if you are eligible for a Special Enrollment Period.
For more information on this topic, please visit www.medicare.gov