Understanding Medicare Part B – Coverage and Costs for 2020September 15, 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
- cardiovascular disease
- 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.
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%.
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.
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.