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Medicare Basics – Part B

Medicare Part B in Depth:

Original Medicare is defined as Part A (Hospital) and Part B (Medical) insurance. For an overview, refer to the article titled, “Understanding Medicare”. For more detail on Part A of Medicare, see “Medicare Part A in Depth”. For more on Part B, read on…

Part B of Original Medicare helps cover approved, medically-necessary services such as for doctors, outpatient care, certain home health care services, durable medical equipment, and others. Part B also covers many preventive services which are covered in a separate article titled, “Medicare Preventative Services in Depth”.

Your Part B Responsibilities for Services Rendered:

Medicare beneficiaries must start out by paying for all medical costs until the yearly Part B deductible is met before Medicare begins paying its share. Thereafter you usually pay 20% of the Medicare-approved amount for the service. The doctor or other health care provider must accept assignment, meaning he/she is approved and agrees to accept the Medicare fee schedule and conditions. If your provider does not accept Medicare assignment, they are permitted to charge up to 15% more for their services. There is no yearly limit for your out-of-pocket medical expenses.

Medicare beneficiaries will typically be responsible for 20% of the Medicare-approved amount, and the Part B deductible applies to all of the following services unless otherwise noted:

Ambulance Services
When medically necessary and then only to the nearest medical facility.

Ambulatory Surgical Centers
Where relatively minor surgical procedures are performed and the patient is released within 24 hours.

Blood
This would be the same as for Part A where you pay for the first 3 units.

Cardiac Rehabilitation
Part B covers services administered in a doctor’s office. If received in a hospital outpatient setting, you would also pay the hospital copayment.

Chemotherapy
Services administered in a doctor’s office, freestanding clinic, or in a hospital outpatient setting. If administered in a hospital inpatient setting, it would be covered under Part A Hospital Care.

Chiropractic Services
This is limited to only helping to correct a subluxation of the spine using manipulation, when one or more of the bones of the spine move out of position.

Clinical Research Studies
Only upon approval by Medicare.

Defibrillator (Implantable Automatic)
You also pay the hospital copayment, if applicable, but no more than the Part A hospital-stay deductible. (If surgeries to implant defibrillators are in a hospital inpatient setting, it would be covered under Medicare Part A Hospital.) {Link to page.)

Diabetes Supplies
Supplies are covered but Medicare Part B only covers insulin if it is used with an external insulin pump.

Doctor and Other Health Care Provider Services
Includes outpatient and some doctor services received as an inpatient. The exception would be for certain preventive {Link to page.) services.

Durable Medical Equipment
This would be for medically necessary equipment such as walkers, braces, oxygen equipment and wheelchairs.

EKG (Electrocardiogram) Screening (unless a part of your one-time “Welcome to Medicare” preventive visit)
If you have the test at a hospital or a hospital-owned clinic, you also need to pay the hospital copayment.

Emergency Department Services

Eyeglasses
Limited to just one pair of eyeglasses with standard frames (or one set of contact lenses), and only after cataract surgery that implants an intraocular lens.

Federally-Qualified Health Center Services
You would pay nothing for most preventive services.

Foot Exams and Treatment
Podiatry is only covered if you have diabetes-related nerve damage and meet certain conditions. You would also have to pay the hospital a copayment, if applicable.

Hearing and Balance Exams
These are covered when ordered to determine if you need medical treatment. If applicable, you would also pay the hospital copayment. (Medicare does not cover standard hearing aids or exams for fitting them.)

Home Health Services
You pay nothing for Medicare approved home health services. (Remember, Medicare does not cover custodial or long-term care.)

Kidney Dialysis Services and Supplies
Generally, Medicare covers dialysis treatment three times a week if you have End-Stage Renal Disease (ESRD).

Kidney Disease Education Services
This is covered by Medicare for up to six sessions of kidney disease education services if you have Stage IV kidney disease.

Laboratory Services
You pay nothing for these services.

Mental Health Care (outpatient)
Generally, you pay a slightly higher copayment than the standard 20%. The Part B deductible applies for both visits to diagnose or treat your condition.

Occupational Therapy
Covered within certain limits.

Outpatient Hospital Services
Covered by Part B, but you will usually pay the hospital any copayment if applicable, but it cannot be more than the Part A hospital-stay deductible.

Outpatient Medical and Surgical Services and Supplies
Covered, but you will usually also pay the hospital copayment however, it can’t be more than the Part A hospital-stay deductible.

Physical Therapy
Covered within certain limits.

Prescription Drugs
Covered within certain limits. This would typically be for certain injections received in a doctor’s office, specific oral cancer drugs, drugs used with some types of durable medical equipment (such as a nebulizer or external infusion pump), and under very limited circumstances, certain drugs received in a hospital outpatient setting. The remaining prescription drugs would be covered by Medicare Part D if you have it. {Link to page.)

Prosthetic/Orthotic Items
Covered if provided by a supplier that’s enrolled in Medicare.

Pulmonary Rehabilitation
You would also pay the hospital copayment, if applicable.

Rural Health Clinic Services
You would pay nothing for most preventive services.

Second Surgical Opinions
Covered when approved by Medicare.

Speech-Language Pathology Services
Covered within certain limits.

Surgical Dressing Services
You pay a fixed copayment for these services when they are received in a hospital outpatient setting. You pay nothing for the supplies.

Telehealth
This is limited to certain circumstances within approved medical facilities (not from a private residence).

Tests (other than lab tests)
If performed at a hospital as an outpatient, you may also pay the hospital copayment, but it cannot be more than the Part A hospital-stay deductible.

Tobacco Use Cessation Counseling
Covered within certain limits.

Transplants and Immunosuppressive Drugs

Travel
When traveling outside the United States – coverage is very limited to certain circumstances and for emergencies only.

Urgently-Needed Care
If applicable, you would also pay the hospital copayment.

Remember that Part B also covers many preventive services which are listed in a separate article titled, “Medicare Preventative Services in Depth”. {Link.)

Private insurance companies that meet Medicare standards have stepped in to help “fill in the gaps” that Medicare does not cover, as pointed out in this article. To learn more, read our article titled, “Medicare Supplement Insurance Policies (Medigaps)”.

To find out if Medicare covers a service which is not listed, visit www.medicare.gov/coverage or call 1-800-MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048.

For more information about Part B Hospital insurance (and more), a great resource is The Medicare & You Handbook. This is CMS Publication # 10050 and can be viewed or downloaded at http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf.

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