Pete Keers
Original Medicare (Part A and Part B) offers many benefits, but it has some "gaps." The most...
Getting Started with Medicare: Part B Essentials
Along with Medicare Part A, Part B is the other part of Original Medicare. A recent blog post described Medicare Part A coverage for inpatient care (hospital and skilled nursing), hospice care, and home healthcare.
Medicare Part B covers medically necessary costs for:
- Doctors
- Outpatient care
- Home health services
- Durable medical equipment
Medicare Part B Costs
Medicare Part B differs from Part A in terms of cost. Most notably, beneficiaries pay a monthly premium cost, whereas most people don't have a Part A premium. In 2022, most people will pay the standard Part B premium amount of $170.10. However, it can be more depending on income. If modified adjusted gross income on IRS tax return from 2 years ago exceeded $91,000, the monthly amount could be anywhere from $238.10 to $578.30.
Part B premiums are deducted from social security benefits. For Medicare beneficiaries not receiving social security, a monthly bill is payable through check, credit card, or other methods.
Other costs such as deductibles, coinsurance, and copayments apply for healthcare services rendered under Part B. For example, the 2022 Part B annual deductible is $233. Once this is paid, coinsurance kicks in at 20%. This means the beneficiary is responsible out-of-pocket for 20% of qualified healthcare costs after the deductible. (Note that some preventative services have a $0 deductible or coinsurance.)
It is important to be aware that there is no annual limit on what a beneficiary pays out of pocket for Original Medicare. However, supplemental coverage like Medigap, Medicaid, or Medicare Advantage may provide caps on the annual amount paid.
If a beneficiary has Original Medicare, the specific costs Medicare covers are detailed in "Medicare Summary Notice" (MSN). This document lists all the services billed to Medicare. It is not a bill. It simply shows what Medicare paid for services, supplies, or equipment.
Assignment – The Big "If" in Medicare Part B
Medicare Part B covers a wide range of healthcare services and products. However, coverage only applies if the provider accepts "assignment." This means accepting Medicare-approved reimbursement amounts for a service or product as payment-in-full. This aids beneficiaries in the form of lower out-of-pocket costs. Typically, the provider bills Medicare first before billing the beneficiary.
However, not all providers accept assignment for all services covered by Medicare. Some may accept assignment for some services and not others. These providers are considered "non-participating." A possible impact on the beneficiary could be a requirement to pay all fees upfront for Medicare-covered services, followed by applying for Medicare reimbursement.
What's Covered – Doctor Fees
As mentioned above, a major part of what Part B covers is doctor's fees. The list of services and products covered is extensive. Especially important are preventive services. These services provide a dual benefit in maintaining a higher quality of health for beneficiaries while simultaneously lowering costs for Medicare. Examples of preventive services are:
- Alcohol misuse screenings & counseling
- Annual "Wellness" checkups
- Bone density measurements
- Cancer screening
- Cardiovascular disease screenings
- Depression screenings
- Diabetes screenings
- Glaucoma tests
- Hepatitis C, HIV, and sexually transmitted infections screening
- Mammograms
- Nutrition and obesity screenings & counseling
- Shots like COVID-19, flu, and Hepatitis B
- Tobacco use cessation counseling
While Part A covers inpatient care, Part B covers outpatient services. There are differences in costs for outpatient treatment in a hospital versus a doctor's office. Therefore, a beneficiary's coinsurance and copayment amounts may be higher in a hospital outpatient setting.
Mental health needs are covered under Part B outpatient services. Examples are counseling or therapy done in a provider's office or hospital outpatient department with such professionals as:
- Psychiatrist
- Clinical psychologist, social worker, or nurse specialist.
- Nurse practitioner
What's Covered – Home Health Services
Like Part A, Medicare Part B covers some home healthcare costs. Examples are:
- Part-time skilled nursing
- Therapies like speech, physical or occupational
- Home health aide
For Part B, a Medicare-certified home health agency must provide services. Also, a doctor needs to have a face-to-face visit to certify that the beneficiary needs in-home health services.
What's Covered – Durable Medical Equipment
Medicare Part B will cover medically-necessary durable medical equipment (DME- e.g., wheelchair) and other medical supplies. Part B deductibles and 20% coinsurance apply, assuming that the DME supplier accepts assignment. DME can be either purchased or rented.
What's Not Covered
Original Medicare does not cover all services or products. Examples are:
- Normal vision, hearing, and dental care services, including routine checkups and items like eyeglasses, hearing aids, and dentures.
- Home safety products like grab bars, stairlifts, or medical alert systems. Sometimes Medicare will cover things like a lift seat to get up from a chair.
- Custodial care in long-term care facilities. In these situations. Medicare covers medical needs but does not help with daily activities like eating or dressing.
- Cosmetic surgery or gym memberships.
- Except in unusual situations, medical services out of U.S. territory are not covered.
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