What Does Medicare Part B Cover?

When you’ve reached the age of 65 and are thinking about enrolling in Medicare for your medical insurance, you should know that the main components of Medicare include Part A and Part B Plans. Both Medicare Parts A and Part B coverage are essential if you want to cover a wide range of medical costs and expenses. Since there are specific guidelines that you need to follow if you want to properly enroll in Medicare Part B, you should gain a better understanding of what Medicare Part B covers and what you need to qualify for this type of Medicare coverage. It’s also essential that you understand the costs of a Part B plan to better determine if you’ll be able to afford it.

What Is Medicare Part B?

Medicare Part B insurance is one of the two parts of original Medicare that you can enroll in when you meet certain guidelines. This form of Medicare health insurance is designed specifically to provide coverage for medical supplies and medical services that are deemed to be medically necessary for the treatment of a health condition that you’re suffering from. This can include anything from ambulance services to outpatient care. Along with medically-necessary services, a Medicare Part B plan will also provide you with coverage for certain preventive services, which includes any kind of health care that can help you prevent illness or detect something like cancer when it’s still at an early stage.

Some of the many medically-necessary services that are covered by a Medicare Part B plan include durable medical equipment like wheelchairs, ambulance services, mental health services in a variety of capacities, and obtaining a second opinion before you receive a surgical procedure. The preventive and screening services that are covered by a Part B plan are extensive and include common services like:

  • HIV screenings
  • Lung cancer screenings
  • Mammograms
  • Glaucoma testings
  • Diabetes screenings
  • Numerous screenings for colorectal cancer

If you’re wondering if your Part B plan will cover a certain health care service, make sure that you ask your doctor or other health care provider if the services will be covered by Medicare.

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Medicare Part B Qualifications

Before you attempt to enroll in a Medicare Part B plan, it’s first important that you determine if you qualify for this type of Medicare. If you know that you’ve already qualified for a Part A plan, you will automatically qualify for a Part B plan. Once you’ve enrolled in a Part A plan, a Part B plan will be available to you as long as you pay a monthly premium. If you’re not directly eligible for a Medicare Part A plan that doesn’t come with a premium, you may be able to qualify for a Part B plan if you meet such requirements as:

  • Being a U.S. citizen or permanent resident of the country for a period that’s no less than five years
  • Being at least 65 years of age or older

It’s also possible to qualify for enrollment into a Part B plan if you are considered to be disabled. In the event that you are below the age of 65 and have received disability benefits via the Railroad Retirement Board or Social Security, your enrollment into Part A and Part B of Medicare will occur after you’ve received disability benefits for a period of two years. Certain individuals may also be eligible for enrollment into one of these plans if they suffer Lou Gehrig’s disease or end-stage renal disease. If you’ve been diagnosed with one of these diseases, you don’t need to be at least 65 years old to enroll.

When to Apply for Medicare Part B? 

Once you’ve ascertained that it’s possible for you to enroll in a Medicare Part B plan, you must then identify when you need to apply for this plan. If you’re already receiving retirement benefits before you’ve reached 65 or you qualify for Medicare because of a disability, you will automatically be enrolled into both Part A and Part B immediately after you’ve become eligible.

If you fail to enroll into Medicare Part B at the allotted time and you’re unable to obtain qualification for a special period of enrollment, you will have the ability to officially sign up at any time during the general enrollment period, which occurs annually from the 1st of January to the final day of March. If you sign up for Medicare Part B during the general enrollment period, your coverage will begin on the 1st of July.

Keep in mind that you may be required to pay a late enrollment fee. The late enrollment penalty for Medicare Part B is typically as much as 10 percent of the premium for every year-long period when you were eligible for Medicare Part B but did not sign up as you were supposed to. This late enrollment penalty will need to be paid for as long as you continue to be enrolled in a Medicare Part B plan. However, this penalty won’t need to be paid if you have already qualified for the special enrollment period.

If you haven’t automatically been enrolled, you can sign up for Medicare Part B through several different sources, which include via the website for Social Security and by visiting a nearby Social Security office. Once you’re 65 years or older and have already signed up for Medicare Part B, the open enrollment period for Medigap will also begin, which lasts for six months. It’s during this time that you’ll have the ability to purchase any one of the ten available Medigap plans, which can cover some of the extra costs that aren’t automatically covered by Part A or Part B.

What Drugs are Included in Medicare Part B?

When you want your current and future medications to be covered by Medicare, you will typically be required to purchase a Part D plan, which is designed specifically to cover many different prescription medications. However, a limited number of outpatient prescription drugs are covered by Medicare Part B, which you should be aware of before you consider enrolling into a Part D plan. If the medications that you require are already covered by Medicare Part B, there might be no reason to enroll in an additional plan.

In most cases, the medications and drugs that are covered by Medicare Part B are ones that you wouldn’t normally give to yourself, which includes medications that are provided during a visit to the doctor and medications that are provided in a hospital outpatient setting. Some of the various drugs that are covered by Part B include:

  • Drugs that are used as a part of durable medical equipment, which can include a nebulizer or an infusion pump
  • Blood clotting factors that are typically administered via injection for the treatment of hemophilia
  • Certain types of antigens
  • Infused or injectable drugs that are administered by an appropriate medical provider
  • Osteoporosis medications that need to be injected, which is only possible if you’re physically unable to provide yourself with the injection
  • Certain injectable medications for anemia or end-stage renal disease

Some of the other medications that can sometimes be covered with Medicare Part B include various vaccinations like flu shots and Hepatitis B shots, transplant drugs for recovery from an organ transplant, intravenous immune globulin, and intravenous or tube feeding, the latter of which may be necessary if nutrition can’t be absorbed through your intestinal tract or if you’re unable to take food directly by mouth. If you require transplant drugs but don’t believe that Medicare Part B covers the ones that you require, a Part D plan usually covers some additional transplant medications. Since these medications are very expensive in most cases, you’ll want to determine which aspect of Medicare provides coverage for these drugs as soon as possible.

A small selection of oral cancer drugs and oral anti-nausea drugs may also be covered with Medicare Part B. When a medication is covered by a Part B plan, you will still be required to pay 20 percent of the costs as well as the Part B deductible if it applies. For all other drugs, you will be required to pay 100 percent of the costs unless you’ve enrolled in a Part D plan.

What Medications Aren’t Covered By Medicare Part B?

If you’re wondering whether or not a Medicare Part B plan covers the types of drugs and medications that you need, these plans don’t provide coverage for any medication that’s covered by a Part D prescription drug plan. For a Part D plan, most policies cover brand-name and generic prescription drugs. The list of covered drugs will include at least two medications in all categories of prescription medications. However, the provider of the plan can make the decision on which specific drugs are covered in each category.

Every Part D plan is also required to cover all medications that are available in such categories as:

  • Anti-cancer drugs that aren’t covered by a Part B plan
  • Anti-psychotic medications
  • Immunosuppressant drugs
  • Anti-convulsive treatments, which are used for seizure disorders
  • HIV and AIDS treatments
  • Antidepressant medications

A Part D plan will also cover any vaccine that isn’t already covered by Part B. The drugs that aren’t covered by a Part B plan or Part D plan include over-the-counter drugs and medications that are designed to help with weight loss.

Not only is prescription drug coverage not included in the Medicare program, but it also isn’t included in any Medicare Supplement. You will need to purchase one of these prescription drug insurance plans separately. 

Alternatively, you can sign up for a Medicare Advantage plan. With these Medicare plans, you will rely on separate, private health insurance for cost-sharing for your medical care costs. You will no longer be considered to be enrolled under Medicare Part A or Part B, but you won’t have to pay all of the coinsurance, copayment and other costs that you’d have to pay with your Medicare Part B coverage. This is an option you can consider during your initial enrollment period around your 65th birthday, but you’ll want to plan carefully. Some plans include extra coverage like prescription drug coverage, coverage for hearing aids and more, but others don’t, so you’ll need to compare plans.

How much is Medicare Part B Premium and Deductible Costs? 

The costs that you will be required to pay when enrolling into Medicare Part B are typically very low. However, the exact amount that you pay depends on a variety of factors, the most important of which relates to your income level. The premiums for Medicare Part B changes somewhat each year. If you’re receiving social security, the premiums will automatically be deducted from the monthly social security benefits that you receive. The average Part B premium for 2019 is at $135.50, which is available for anyone who files an individual tax return of $85,000 or less. This monthly premium amount can also be obtained if you filed a joint return of $170,000 or less. Since the majority of people who receive Medicare Part B fall at or below this income requirement, the monthly premium will almost always be $135.50.

If you’ve filed an individual return or joint return that’s higher than these amounts, you may be required to pay more for your monthly premium. For instance, if you filed an individual tax return that was above $160,000 but below $500,000, you would be required to pay a monthly premium of $433.40. When your individual tax return is above $500,000 or your joint tax return is above $750,000, you’ll need to pay $460.50 each month. This is currently the highest bracket available, which means that you’ll pay the same amount if your last tax return was $2 million.

Along with a monthly premium, you’ll also be required to pay a certain deductible throughout the year, which is the amount of money that you need to pay before Part B benefits kick in. The annual deductible for 2019 is set at a low $185. You will also need to pay a 20 percent copayment fee for many of the services that are covered under Medicare Part B. With these premium and deductible costs in mind, you should be able to determine if you can afford such expenses.

Understanding Medicare Part B Excess Charges

Medicare Part B excess charges can occur in the event that a doctor or health care provider charges more to Medicare than the amount that has been approved by Medicare. When a doctor accepts “assignment”, they are agreeing to accept the amount approved by Medicare as full payment for the services that they’ve provided. If a doctor does not accept this, they can overcharge the standard Medicare rate for service by as much as 15 percent. If you visit a doctor who does not accept the amount approved by Medicare, you may be required to pay the excess charge, which can be costly depending on the type of service that you’ve received. However, it’s possible to file a claim directly with Medicare that should allow for reimbursement of the money that you paid.

If you visit one or more doctors who charge the extra amount, you might want to consider obtaining a supplement plan that covers these charges, which is a benefit that’s provided by Medigap Plans N, F, and G. You could also avoid these charges completely by asking your doctor if they accept Medicare assignment. If they don’t, you can simply switch to a doctor who does accept Medicare assignment and won’t overcharge. Keep in mind that there are some states that strictly prohibit the practice of overcharging, which include:

  • Minnesota
  • Massachusetts
  • Connecticut
  • Ohio
  • New York
  • Rhode Island
  • Pennsylvania
  • Vermont

If you live in any one of these states, you don’t need to worry about excess charges. 

Despite the Medicare Part B costs that are not covered, overall, it is a helpful program. Between Medicare Parts A and B, you can get help with home health care/home health services, doctor visits, preventive care, physical therapy, care for ESRD and more. Plus, you can always Supplement the program with a Medicare Supplement if you want to, or you can determine if you’re eligible for Medicaid services. If you need help with making the most out of your Medicare coverage, give us a call and talk to one of our licensed insurance agents today.