Part B: The Second Piece of the Medicare Puzzle


Medicare Part B is one of four parts that make up Medicare benefits. Each part provides coverage for different services and comes with its own terms for payment and use.

Just as with traditional health insurance, there are many things to learn about Medicare.

Let's take a detailed look at Medicare Part B, including what it covers, what it costs, who is eligible and how to enroll. We will also talk about what it does not cover and how HealthMarkets can help you find additional coverage or help with cost for when you need it.


What is Medicare Part B?

Medicare Part B is medical insurance that provides coverage for services such as outpatient care, preventive services, ambulance services and more.  

Here are some of the services covered by Medicare Part B.

Outpatient Care

While Medicare Part A covers inpatient care (such as hospital or skilled nursing home stays), Medicare Part B provides benefits for outpatient services that are deemed medically necessary. Such covered services include:

  1. Emergency or observation room services
  2. Same-day surgery or stitches
  3. Laboratory tests
  4. Mental health care in a partial hospitalization program
  5. Radiology services including x-rays

Preventive Services

Upon enrolling in Medicare Part B, you’ll be eligible for a “Welcome to Medicare” preventive visit that includes a review of your medical history and education about preventive care. After your first year under Medicare Part B, you’ll be eligible for an annual wellness visit in which you’ll undergo a health risk assessment.

In addition to the “Welcome to Medicare” visit and the yearly wellness visit, some of the preventive services covered by Medicare Part B include:

  1. Abdominal aortic aneurysm screening
  2. Alcohol misuse screening and counseling
  3. Bone mass (bone density) measurement
  4. Breast cancer screening/mammograms
  5. Cardiovascular disease screenings
  6. Cervical and vaginal cancer screening
  7. Colorectal cancer screenings
  8. Depression screening
  9. Diabetes screening and self-management training
  10. Flu shots
  11. Glaucoma tests
  12. Hepatitis B shots
  13. Hepatitis C test
  14. HIV screening
  15. Lung cancer screening
  16. Medical nutrition therapy services
  17. Obesity screening and counseling
  18. Pneumococcal shot
  19. Prostate cancer screenings
  20. Sexually transmitted infection screening and counseling
  21. Smoking and tobacco-use counseling

Ambulance Services

With Part B, you’ll be covered for ground transportation by ambulance to any hospital or skilled nursing facility for medically necessary services or when transportation in any other vehicle could endanger your health. Individuals are only covered for transportation to the nearest medical facility that can provide the type of treatment required.

Ambulance transportation by helicopter or airplane may also be covered by Part B if immediate and rapid transportation is needed but cannot be provided by ground transportation.

Additionally, Medicare Part B covers the facility service fee for approved surgical procedures conducted in an ambulatory surgical center.

Durable Medical Equipment (DME) Coverage

Part B also covers the following durable medical equipment:

  1. Casts
  2. Braces
  3. Splints
  4. Crutches
  5. Wheelchairs
  6. Walkers  
  7. Canes
  8. Oxygen equipment
  9. Therapeutic shoes
  10. Diabetes supplies like blood sugar testing monitors and insulin
  11. Defibrillators
  12. Prosthetics and orthotics
  13. Eyeglasses and contact lenses following cataract surgery that implants an intraocular lens
  14. Kidney dialysis equipment
  15. Support surfaces including some mattresses and hospital beds

While Medicare Part A provides home health care coverage following a hospital stay, Part B can provide coverage if no hospital stay was needed.

In order to be eligible for home health care coverage under Part B, you must have trouble leaving your home without help (such as using a wheelchair, special transportation or help from another person) due to an illness or injury and leaving your home is not recommended due to your condition.

Therapeutic and Rehabilitative Care

Medicare Part B provides coverage for a number of therapeutic and rehabilitative services. Some of these include:

  1. Cardiac rehabilitation
  2. Chiropractic services (limited basis)
  3. Occupational therapy
  4. Physical therapy
  5. Pulmonary rehabilitation
  6. Speech therapy
  7. Continuous Positive Airway Pressure (CPAP) therapy

Chemotherapy

Outpatient chemotherapy that takes place in a doctor’s office, freestanding clinic or hospital can be covered under Part B. Part A covers the hospital stay if you are admitted as an inpatient.

Limited Prescription Drugs

Medicare Part B does not offer coverage of prescription drugs that are used at home. Medicare Part D focuses on covering the cost of prescription drugs (more on that later). However, Part B does offer coverage for flu shots, immunosuppressant drugs and drugs that are used in accordance with certain types of medical equipment.

Under certain circumstances, Part B will provide coverage for heart, lung, kidney, pancreas, intestine and liver transplants when performed in Medicare-certified facilities.

Part B Eligibility

There are two requirements that need to be met in order to be eligible for Medicare Part B:

  1. You must be at least 65 years old and already receive benefits from Social Security.
  2. You must be at least 65 years old and already receive benefits from the Railroad Retirement Board (RRB).
  3. You have Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease.
  4. You live in Puerto Rico and receive benefits from Social Security or the RRB.

Part B Enrollment

There are three causes for automatic enrollment:

  1. If you’re receiving Social Security or Railroad Retirement Board benefits, you’ll automatically be enrolled in Medicare Part A and Part B once you turn 65 years old.
  2. If you’re under 65 but are getting disability benefits from either Social Security or the Railroad Retirement Board, you’ll receive Part A and Part B after 24 months of such benefits. 
  3. If you have ALS (Lou Gehrig’s disease), you’ll receive Part A and Part B the month after your Social Security disability benefits begin.

If you’re not eligible for automatic enrollment in Medicare, you’ll have to sign up yourself during one of three enrollment periods.

The “initial enrollment period” is a seven-month period that begins three months before you turn 65, includes the month you turn 65 and ends three months after turning 65.

If you sign up during the first three months of the initial enrollment period (prior to turning 65), your Medicare coverage will begin on the first day of the month in which you turn 65. If enrollment occurs during the last three months of the seven-month window, your coverage will be delayed.

The “general enrollment period” lasts from January 1 to March 31 every year. If you sign up during this time, your benefits won’t begin until July 1 and you may have to pay a late enrollment fee.

The “special enrollment period” applies to those who did not sign up for Medicare during either the initial or general enrollment periods because they were still working and/or were still covered by a group health insurance plan.

The special enrollment period is an eight-month period beginning the month after employment or group coverage ends, whichever happens first. There is no late enrollment fee for signing up during the special enrollment period.

Part B Costs

Below is a breakdown of the costs associated with Medicare Part B:

Monthly premiums. While Medicare Part A has a zero-dollar premium for most people who paid Medicare taxes while working, Part B comes with a monthly premium. The standard premium can fluctuate year-to-year. In 2015, it was $104.90. In 2016, it’s $121.80 for those who enroll in Part B for the first time or don’t get Social Security benefits.

However, some people will have to pay more than the standard premium. If your modified adjusted gross income on your tax return from two years ago was more than $85,000 for an individual or $170,000 for those filing jointly, you will pay more than the standard premium.

Deductible. Medicare Part B comes with a yearly deductible of $166. After meeting this deductible, you’ll typically pay a 20 percent coinsurance of the Medicare-approved amount for services rendered.

Late enrollment fees. Depending on the circumstances, you may have to pay an increased premium every month for as long as you remain enrolled in Part B.

The Other Parts of Medicare

Of course, Part B is just one component of Medicare. In order to better understand Part B, it helps to also understand the other three parts, which are named Part A, Part C and Part D.

When you combine Medicare Part A with Medicare Part B, you have what’s called “Original Medicare.” This two-part combination is a fee-for-service health plan facilitated by the federal government. Original Medicare is a way to receive both inpatient (Part A) and outpatient (Part B) coverage under one plan.

Medicare Part A

Medicare Part A is hospital insurance and this is the standard or default type of Medicare coverage. When you sign up for Medicare, you are automatically enrolled in Part A. Part A is no cost for eligible patients who have paid Social Security taxes for at least 10 years. Fewer than 10 years of Social Security contributions will require a monthly premium for Part A.

Services covered under Part A include:

  1. Inpatient hospital care. Part A covers up to 90 days of general hospital stays for each benefit period plus an additional 60 lifetime reserve days. Part A will also cover up to 190 lifetime days in a psychiatric hospital that is Medicare-certified.
  2. Skilled nursing facility (SNF) care. If you are in the hospital for three consecutive days within the 30 days prior to admission to a skilled nursing facility, up to 100 days of care can be covered by Part A. To be eligible for coverage, you must require skilled nursing services seven days a week or require physical, occupational or speech therapy services at least five days per week.
  3. Home health care. If you spend at least three days in the hospital within 14 days prior to receiving home health care services, you can be eligible for up to 100 days of covered care under Part A.
  4. Hospice care. An unlimited number of hospice care days are covered under Part A provided that your doctor has certified that you are terminally ill and that your life expectancy is six months or less.

Medicare Part C

These plans are called Medicare Advantage Plans and come in the form of an HMO, PPO or POS, just as with traditional health insurance. These plans cover the same benefits as Original Medicare. The flexibility lies in the extra benefits that each may provide, including prescription drugs, dental or vision benefits that are not covered by Original Medicare.

In order to be eligible for Part C, you must first enroll in parts A and B. Part C plans may require a monthly premium in addition to a Part B premium and can come with varying terms, rules and restrictions.

In 2015, there were nearly 2,000 different types of such plans made available.

Medicare Advantage plans can serve as a flexible alternative to traditional Medicare options. And at HealthMarkets, we work with more than 180 insurance providers nationwide to help people just like you find a Medicare Advantage plan. Contact one of our 3,000-plus licensed agents today to get started.

Medicare Part D

Coverage for prescription drugs can be acquired through a Medicare Advantage (Part C) plan or through Part D. Medicare Part D is a prescription drug plan (PDP) available only through private insurance companies.  

There are many different Part D plans available, and each have their own list of drugs that are covered under the plan. One of the advantages of Part D is that these plans have permission to cover some drugs that Original Medicare is legally prohibited from covering.

Many Part D plans will restrict customers to pharmacies located within the plan’s network.

If you have any further questions about Medicare Part B including coverage, costs, eligibility or enrollment, call one of our licensed agents today at (855) 839-8126.

About the Author: Luci Lopez

Luci is a visual storyteller (10 years!). Baker. Dog lover. Proud UTPA and UNT alumna. Curious about the unknown.

HMIA002501

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Sources:
"What Part B covers | Medicare.gov." 2012.
"Manual Name - Centers for Medicare & Medicaid Services." 2012.
"Medicare and Home Health Care (PDF). - Medicare.gov." 2012.
"When can I sign up for Part A & Part B? | Medicare.gov." 2012.
"Enrolling in Medicare Part A & Part B (pdf) - Medicare.gov." 2015.
"Medicare Part B Enrollment Periods - Medicare Rights Center." 2011.
"Medicare Interactive - Medicare Part B costs." 2009.
"Your Medicare Costs - WebMD." 2013.
"Medicare Advantage 2015 Data Spotlight: Overview of Plan ..." 2014.

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