Understanding Medicare Part B – Coverage and Costs for 2020

What Is Medicare Part B?

Medicare is a federal government health insurance program for seniors 65 and older and others who meet qualifying conditions.

Medicare consists of four parts, labeled A, B, C, and D. Parts A and B make up the government-funded “Original Medicare” program. Part C refers to “Medicare Advantage” plans, which provide additional medical insurance. Part D refers to separate prescription drug Medicare plans. 

Part A covers costs associated with hospitals and other inpatient services. It’s complemented by Part B, which covers outpatient services, preventative care, and durable medical devices.

Some people are automatically enrolled in Parts A and B while others must enroll on their own. 

What is the difference between Part A and Part B Medicare?

Part A is often referred to as Medicare “hospital insurance,” while Part B Medicare coverage is often referred to as “medical insurance.” What this means is that while Part A can cover hospital stay charges, Part B can cover your doctor’s appointments and preventative care. If you had Part A only, you would have coverage for hospital care, but not any of your doctor’s appointments, so it’s important to enroll in both. 

Medicare Part B Coverage

At this point, you’re probably wondering, “what does Part B of Medicare pay for?” 

Medicare Part B covers ambulance services, doctor visits, preventative services, mental health, women’s health services (like mammograms), lab tests and X-rays, some medical equipment, and more. It does NOT cover hospital stays or most prescription drugs. The only time that Part B will cover drugs is if the drug is administered by a medical professional.

Medicare Part B Drugs

Here is a list of drugs covered by Medicare Part B:

  • Drugs used with durable medical equipment, like nebulizer supplies
  • Antigens, when prepared and administered by a doctor
  • Injectable osteoporosis drugs if medically necessary 
  • Erythropoiesis-stimulating agents for those with ESRD or anemia related to other conditions
  • Oral ESRD drugs
  • Blood clotting factors for those with hemophilia
  • Other injectable and infused drugs when given by a medical professional

Preventative Services and the Annual Wellness Visit

Medicare Part B includes 100% coverage for several preventative services.

For example, when you first enroll in Part B, you can make a “Welcome to Medicare” appointment with your doctor. This will be a comprehensive overview conversation with your doctor about your healthcare needs and concerns.

You will also be eligible for an Annual Wellness Visit. This is more in-depth and includes a health risk assessment, a review of your and your family’s medical history, measurements (height, weight, BMI, blood pressure, etc.), mental health screenings, and a general conversation about your daily health concerns.

Also included under Part B at 100% coverage are your preventative vaccines, such as annual flu shots. However, some vaccines that are not considered preventative measures are not included under Part B coverage.

For example, the Shingles vaccine would be covered under Part D coverage instead of Part B.

Preventative services are also covered for:

  • high blood pressure
  • high blood sugar
  • abnormal cholesterol
  • obesity
  • glaucoma
  • depression
  • cardiovascular disease
  • HIV
  • smoking and alcohol cessation
  • various cancers

Women are covered at 100% for pap smears, pelvic exams, and breast exams every two years. If you are diagnosed as at-risk for gynecological conditions, you may be able to receive screenings every year instead.

Mental Health

Medicare Part A covers inpatient mental health care. Part B covers outpatient mental health services, including:

  • No-cost yearly depression screenings
  • Both individual and group psychotherapy (including family counseling)
  • Psychiatric evaluations and diagnostic tests
  • Certain prescriptions
  • Medication management
  • Limited partial hospitalization
  • Partial hospitalization refers to psychiatric hospital treatments that don’t require an overnight stay. Items like meals, transportation, and support groups are not included.

You will only receive coverage when you see a doctor or specialist who accepts Medicare. You will be responsible for 20% of most of these services. There may be additional co-payments or coinsurance for partial hospitalization.

IMPORTANT: If you or a loved one is in immediate crisis, call the National Suicide Prevention Lifeline immediately at 1-800-273-8255 (TTY 1-800-799-4889). Help is available 24-7.

Laboratory Tests and X-Rays

When your doctor orders a lab test to help diagnose a condition or as part of your annual checkup, you are covered under Part B. Medically necessary blood tests and other diagnostics sent to a lab are covered.

They include blood work, urine tests, tissue lab work, and some screenings at no cost to you.

Blood for transfusions is handled differently. If you get a transfusion through a blood donation, you may not have to pay anything. Otherwise, you may have to pay 20% of the Medicare-approved amount.

X-rays are also covered but at 80% of the Medicare-approved amount. You are responsible for the other 20%.

Emergency Transportation

Part B can cover emergency transportation if other transportation could put you in danger or you are having a medical emergency and need immediate assistance. It will only cover an ambulance ride to the nearest medical facility that can give you the type of care you need.

You cannot request to visit a hospital that is further away.

Air transportation is covered only if you need to get to a facility quickly and cannot do so by ground transportation (heavy traffic, inaccessible road conditions, etc.)

Transportation is covered at 80% of the Medicare-approved amount, and your Part B deductible will apply.

In some cases, Part B may cover non-emergency ambulance transportation if there is no other safe way for you to get to a hospital or other provider office for medically necessary services.

You will need to schedule your ambulance transportation in advance by reaching out to a non-emergency ambulance transportation company like ACC Medlink and Lifeguard.

The company you select may charge a fee and can contact Medicare to request authorization for coverage.

Durable Medical Equipment

Part B will only cover durable medical equipment.

For an item to be considered durable medical equipment (DME), it must be able to withstand repeated use for at least three years, must be usable at home, and must be used for a medical purpose only. Medicare will cover 80% of the cost.

In some cases, you may be able to choose whether you want to rent or purchase the equipment you need.

Some examples of DME include:

  • Blood sugar test strips and monitors/glucose control
  • Canes, crutches, scooters, walkers, and wheelchairs
  • Continuous passive motion machines
  • Continuous positive airway pressure devices (CPAP)
  • Commode chairs
  • Hospital beds
  • Infusion supplies
  • Lancets and lancet devices
  • Nebulizers and related medication
  • Nutrition supplies/equipment

Check with your doctor or Medicare to see if an item is considered a DME or not.

Long-Term Care

Part B covers some home health care, but only that which is relatively short-term and related to a limited period of recovery due to an illness, injury, or condition. Part B does not cover long-term care, either at home on in a nursing facility, that people may need due to frailty or because they need help with daily activities (bathing, grooming, eating, etc.)

What isn’t covered by Medicare Part B

Medicare Part A and Part B are structured to work together to provide maximum coverage at an affordable cost for most Americans.

This coverage is enhanced by adding optional Part C Medicare Advantage or Medicare Part D drug plan coverage.

In general terms, Part A covers in-hospital expenses, and Part B only covers outpatient expenses, durable medical equipment, and wellness activities.

Medicare does not cover anything not considered medically necessary. That includes elective and cosmetic surgery and several forms of alternative medicine such as homeopathy, acupuncture, and acupressure. Chiropractors are covered on a limited basis.

Other than flu and pneumonia shots, Medicare does not cover vaccinations and immunizations. The exception is if there is a health emergency, and vaccinations are required to stem the risk of infection through a contagious disease.

Part B also only covers drugs you can’t self-administer. Coverage is only provided if you receive medications in a hospital, doctor’s office, or health clinic. This is where Part D coverage can come in handy. All nonprescription drugs and remedies are also not covered under Part B.

General dental work is also not covered, unless it would need to be performed by a physician, meaning the treatment would be considered medical vs. dental

Part B also does not cover vision care, hearing aids, or contact lenses, except those required after cataract surgery. But if your eyes are affected by an illness or injury other than a routine loss of vision, you will be covered for ophthalmological services.

Routine foot care is also not covered unless a foot condition is the result of conditions such as diabetes, cancer, multiple sclerosis, inflammation due to blood clots, chronic kidney disease, malnutrition. Care must be diagnosed as medically necessary.

Except in rare circumstances, medical services outside of the United States and its territories are not covered as well. You will need to enroll in a Medicare Advantage plan for international coverage.

Medicare Part B costs in 2020/2021

Medicare premiums, copayments, and deductibles are adjusted annually according to the Social Security Act. What will Medicare Part B cost 2020 enrollees?

In 2020, the standard monthly premium is rising by about 7% due to increased program costs, up to $144.60. If you already get Social Security or Railroad Retirement benefits, your premium can be deducted from those. Social Security Medicare Part B payments will be automatic for most people. 

The standard deductible is $198. After you pay your deductible, you’ll have to pay 20% for most Medicare Part B services, other than preventative and wellness services detailed above.

There is no income limit for Medicare Part B, but if you have a high gross income, you could be required to pay an Income-Related Monthly Adjustment Amount (IRMAA).

Some people may purchase a Part C plan that offers low deductibles and copays. You will pay a Part C premium, but you could wind up with more comprehensive coverage that will significantly augment existing Part A and B coverage and provide Part D prescription drug coverage as well.

Who qualifies for free Medicare B?

Unlike Medicare Part A, the amount of time you’ve worked does not affect your Part B premiums. Most people will have to pay a premium for Medicare Part B. To qualify for free Part B, you’ll have to qualify for one of the following programs:

  • The Qualified Medicare Beneficiary Program (QMB) helps pay premiums for Part A and Part B, as well as copays, deductibles, and coinsurance.
    • Individual monthly income limit = $1,060
    • Married couple monthly income limit = $1,430
    • Individual resource limit = $7,730
    • Married couple resource limit = $11,600
  • The Specified Low-Income Medicare Beneficiary Program (SLMB) offers premium assistance for Part B. If you are eligible for an SLMB, you also are automatically eligible for an Extra Help program to assist in Part D prescription drug coverage.
    • Individual monthly income limit = $1,269
    • Married couple monthly income limit = $1,711
    • Individual resource limit = $7,730
    • Married couple resource limit = $11,600
  • The Qualified Individual Program (QI) also helps pay Part B premiums. To apply, which you must do every year, contact your state Medicaid program. Enrollments are on a first-come, first-served basis.
    • Individual monthly income limit = $1,426
    • Married couple monthly income limit = $1,923
    • Individual resource limit = $7,730
    • Married couple resource limit = $11,600

Eligibility for Medicare Part B

Medicare Part B eligibility is based on age, citizenship, retirement benefits, and qualifying illnesses. You are eligible for Medicare Part B if:

  • You are 65 or older and a U.S. citizen or permanent legal resident.
  • You are younger than 65 and have qualifying disabilities or suffer from End-Stage Renal Disease or Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig’s disease).
  • You are eligible to receive, or you’re currently receiving Social Security or Railroad Retirement Board benefits.

Check your eligibility by going to the Medicare Eligibility and Premium Calculator.

Medicare Part B Enrollment

If you are aging into the Medicare program, you should enroll in Part B any time between three months before your 65th birthday to three months after. 

One question we hear a lot is, “I already have Part A, can I add Medicare Part B anytime?” Unfortunately, it’s not that simple. If you choose to forgo Medicare Part B when you first became eligible, you could face a late enrollment penalty fee later. Additionally, if you don’t enroll when you first become eligible, you’ll have to wait for the open enrollment period from January 1 through March 31 to enroll.

If you get Social Security or Railroad Retirement Board benefits for at least four months before your 65th birthday, you’ll automatically be enrolled in Part A and Part B coverage. Coverage starts the first day of the month you turn 65.

When you’re under 65, you have a disability, and you have been getting SSDI benefits for at least 24 months, you are automatically enrolled in Part A and Part B. If you suffer from Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease), you are automatically enrolled in Part A and Part B the month your disability benefits begin.

If you have been diagnosed with End-Stage Renal Disease (ESRD), you can enroll in Part A and Part B. To get full benefits that cover dialysis and kidney transplant benefits, you’ll need to be covered by both.

Check with Medicare.gov, because there are several stipulations regarding coverage for ESRD.

You can enroll in Part B during your Initial Enrollment Period (IEP), the General Enrollment Period (GEP), or during Special Enrollment Periods (SEP) if you qualify.

You can sign up for Part B benefits the following ways:

  • Apply online at Social Security.
  • Enrolling at your local Social Security office.
  • Call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778).
  • If you worked for a railroad, call the Railroad Retirement Board at 1-877-772-5772.

Medicare Part B phone number: For questions about Medicare Part B billing, call 1-800-833-4455.

What happens if you don’t sign up for Medicare Part B?

While you are technically not required to sign up for Medicare Part B, you may face a late enrollment penalty fee if you wait too long to enroll. This will come in the form of a premium increase of as much as 10%. 

Can I delay Medicare Part B coverage?

You can delay signing up for Part B coverage, but if you enroll at a later date, you may have to pay an enrollment penalty. This penalty will be in force for the entire time you have Part B coverage.

When you delay Part B coverage, it also means you can’t sign up for a Part C Medicare Advantage plan. One of the requirements for Part C is that you must currently be enrolled in Parts A and B.

Additionally, if you miss your initial enrollment period for enrolling in Part B, you’ll have to wait until the enrollment period from January 1 through March 31 to enroll. 

Can I decline Medicare Part B coverage?

Is it mandatory to have Medicare Part B? No. But make sure you do your homework first and take into consideration your long-term health needs.

Although you have to pay a premium in many cases for Part B coverage, it still makes sense to enroll for a vast majority of people.

What is Medicare Part B Buy Back/Give Back?

Are Medicare Buy Back plans too good to be true?

No!

Can they really put money back into your social security check?

Yes, it’s offered through SOME Medicare Advantage plans but not all.

Here is how it works.

Some Medicare Advantage plans out there that can “buy back” your monthly Part B premiums, ultimately putting money back into your pocket. You’ve likely seen this on TV, but unfortunately it’s misleading as this specific benefit is narrowly used by a few plans across the country.

These plans are effectively paying you instead of the other way around! Let me explain. 

Medicare Part B Premiums in 2022

In 2022, the standard Medicare Part B premium will be $148.50. Your premium may be a bit higher if you have a higher income. Below is a snap shot directly from Centers for Medicare and Medicaid about the current Part B premium scale. 

The reason you have to keep paying this premium is because Medicare Part B is a paid program, unlike Medicare Part A which you earned during your working years by paying social security taxes. By default, everyone has to pay for Medicare Part B unless they get some kind of financial assistance.

While Medicare Part B is a part of original Medicare, Medicare Advantage plans are privately owned and offer additional benefits beyond original Medicare. In particular, Part B buy back is an additional benefit offered by some plans. This is sometimes confusing to many people, so bear with me.

To have Medicare Advantage, you must be enrolled in original Medicare Parts A and Parts B. In order to be enrolled in original Medicare, you must have worked 40 quarters (or 10 years) paying into social security to earn Part A, and then pay a monthly premium for Part B. To stay enrolled, you have to continue paying your premiums!

You can’t get a Medicare Advantage plan without having original Medicare.

Medicare Plan Finder Tool

What are Medicare Advantage Part B Buy Back Plans?

Medicare Advantage plans are additions to your existing Medicare coverage. They can vary greatly in coverage amounts and premium prices. Some Medicare Advantage plans can come with a $0 premium or a low premium in addition to a Part B buy back (or give back, as some plans call it). 

If you pay your Part B premium automatically out of your Social Security check, this could feel like a bonus added to your monthly checks! You’ll start seeing a bit more coming in, which is nice, assuming the plan you choose has the buy back option.

Premium Give Back Plan? What’s the Catch? 

You’re probably skeptical about the idea of an insurance company wanting to give YOU money.

However, there’s not really a catch. According to Quality Health Plans of New York, Medicare Advantage plans “may choose to use some of the funding it receives” to “reduce its members Medicare Part B premium.”

So, what these plans are doing is providing you an incentive to sign up for their plans.

Even if they give you some of that money back for your Part B premiums, they still get paid from your copayments, deductibles, etc.

As you’re looking into available Medicare Advantage plans that offer Part B buy back benefits in your area, be sure to consider what you might be giving up.

Remember, all plans are different, but it is possible that a plan with a Part B buy back option will have higher copayments and deductibles – which may not matter to you if you don’t spend a lot of time in the doctor’s office! The devil is in the details.

I guess you could say the only true “catch” to these plans is that you have to stay enrolled in Medicare parts A and B – but that’s true of any Medicare Advantage plan. You’ll have to continue paying your A and B premiums, even if you do get some of that money back. 

Additionally, it may be a few months after you sign up for your premium give back plan before you receive your first Part B reimbursement. 

How do I Get a Part B Buy Back (Give Back) Plan?

Great question! As you can imagine, these plans might be harder to find than more standard Medicare Advantage plans, and there may or may not be one available in your area. 

Unfortunately, CMS (Centers for Medicare and Medicaid Services) does have certain rules in place that forbid us from sharing the plan details with you publically. However, we have licensed agents across the nation who can meet with you either in person or by phone to help you choose a plan. 

If you’re interested, call us at 800-691-1832. Let us know that you’re interested in Part B buy back plans, and we’ll do all we can to help!
You can also leave us a message here, and we’ll get back to you.

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