Medicare Part B GUIDE: Eligibility, Services Covered, and Costs

Medicare Part B: Eligibility, Services Covered, and Costs

Original Medicare has two parts: Part A (provides inpatient/hospital coverage) and Part B (provides outpatient medical coverage). Certainly, Part B is optional, but it helps you with many outpatient services.

Continue reading to learn more details about Part B, its costs, services covered, and eligibility.

What is Medicare Part B?

Part B of Medicare helps fund medical services such as doctor’s visits, outpatient treatment, and other services that Part A does not cover. In addition, it helps pay for covered medical services and equipment. Part B also includes preventive treatments, including checkups, lab testing, and screening immunizations to help prevent, detect, and manage medical problems.

Medicare Part B is designed to fill the gaps that Medicare Part A does not cover. After the beneficiary achieves the yearly deductible, Part B pays 80% of the “reasonable price” for covered treatments, as defined by Medicare’s reimbursement rate; the beneficiary is liable for the remaining 20% as “coinsurance.” Unfortunately, the “fair rate” is frequently less than the actual charge charged by the service. For example, if a clinician agrees to “accept assignment,” he agrees to take Medicare’s “reasonable charge” rate as full payment, with the patient paying for only 20%. However, if the provider refuses to accept the assignment, the patient will be liable for a part of the difference between Medicare’s reimbursement rate (reasonable fee) and the physician’s charges.

Individuals enrolled automatically in Part B when;

  1. They are receiving Social Security retirement benefits.
  2. They are getting 24 months of Social Security disability benefits.
  3. They are otherwise eligible for Medicare Part A. 

Others must enroll in Part B by requesting the Social Security Administration when they first become eligible.

Services Covered by Medicare Part B

Payment for physician services is the most crucial benefit under Part B. Also included are home health care, durable medical equipment, outpatient physical therapy, x-rays, and diagnostic testing.

The following are the Part B-covered services:

  • Medically essential services provided by a qualified health practitioner are covered under Part B.
  • Durable medical equipment (DME) is medical equipment that has a medical function, can withstand repeated use, and is acceptable for use at home. Examples include walkers, wheelchairs, and oxygen tanks, to name a few. You can buy or rent DME from a Medicare-approved supplier if your doctor prescribes it.
  • Home health care services are covered if you cannot take physician visits or move around properly for specialist nursing or therapy.
  • Medicare Part B also covers Ambulance services to and from hospitals. Non-emergency ambulance/ambulette transportation is only covered when there is no other safe mode of transportation available, and the transportation is medically essential.
  • Preventive treatments include tests and counseling designed to keep you healthy by preventing sickness, detecting problems, and preventing illness are also covered. Part B frequently covers preventive care with no coinsurance.
  • Part B also covers outpatient physical, speech, and occupational therapy treatments if the provider accepts Medicare.
  • X-rays and lab tests are also covered as an outpatient service.
  • Part B covers chiropractic therapy which is utilized when spinal manipulation is medically necessary to rectify a subluxation (when one or more of the spine’s bones shift out of place).
  • Some medications covered under Part B are immunosuppressant, specific anti-cancer treatments, some anti-emetic drugs, and some dialysis drugs that a physician typically prescribes.

This list, while not inclusive, includes some of the most often covered services and goods. Remember that Part B does not usually cover the total cost of your treatment, and you will almost probably be responsible for some cost-sharing (deductibles, coinsurance, and copayments) for Medicare-covered treatments.

Am I Eligible for Medicare Part B?

If you’re eligible for a free Medicare Part A, you become eligible for Part B. However, if you don’t qualify for a premium-free Part A, you can still enroll in Part B (even without enrolling in Part A) by fulfilling the below criteria.

  • You should be at least 65 years old.
  • You must be a United States lawful permanent resident who has lived in the United States for at least five years.

You can also become eligible for automatic enrollment in Medicare Part B if you are disabled. For instance, if you are under 65 and receiving Social Security or Railroad Retirement Board (RRB) disability benefits, you will be automatically enrolled in Medicare Part A and Part B. You can be qualified for Medicare before turning 65 in this case. For example, suppose you have End-Stage Renal Disease (ESRD) or amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s illness), you can enroll in Medicare Part B before turning 65.

Medicare Part B Costs

Medicare’s Part B is optional and is mainly financed by monthly premiums paid by individuals enrolled in the program.

If you have Part B, you must pay a monthly fee, i.e., a premium. The majority of patients will pay the usual premium. However, your premiums depend on your income — high income attracts higher premiums. Besides premium, you also expose yourself to a late enrollment penalty if you don’t sign up for Part B when you initially become eligible.

A vital issue with Medicare Part B, as previously stated, is the disparity between the cost of medical commodities or services, notably physician services, and the Medicare-approved “reasonable fee.” When Medicare covers an item/service, the patient is liable for the remaining 20% of the “reasonable fee” for that item or service. Regrettably, the “reasonable amount,” determined by Medicare, is sometimes far lower than the actual charge. As a result of the “reasonable charge” reimbursement structure, Medicare payment is sometimes insufficient, even for commodities and services covered by Part B. These out-of-pocket payments come on the patient.

When a physician accepts “assignment,” they agree to accept the full payment from Medicare. If a physician refuses to accept assignment, the patient is responsible for the copayment and any remaining debt over the Medicare fee. However, a physician’s balance bill cannot exceed a certain amount under federal law. Therefore, only 115 percent of the scheduled Medicare amount will be permissible for the service provided by the physician. For instance, assume you visit a doctor who refuses to accept insurance; his total price maybe $100, but the Medicare fee schedule only allows for $70. Therefore, if the doctor invoices more than $80.5, he breaks the law.

If you want to enroll in Medicare Part B, Simpler Horizons Insurance Solutions can help you. Our licensed agents specializing in Medicare are there to assess your medical needs and help you find a suitable plan and the correct enrollment period for you.

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