Every Medicare beneficiary will start with “Original Medicare,” which includes Medicare Part A and Medicare Part B. Part B is responsible for covering your doctor visits. Some people will be automatically enrolled in Part B at the same time that they are automatically enrolled in Part A, while others will have to enroll on their own.
Part B covers medically necessary doctor services and treatments as well as preventive services like yearly wellness visits. This includes your laboratory tests, x-rays, emergency transportation, durable medical equipment, mental health, and partial hospitalization.
For most doctor services, other than preventative benefits which are often covered at 100%, you will be responsible for 20% of the Medicare-approved amount.
Medicare Part B includes 100% coverage for a few different types of preventative services. The first is your “Welcome to Medicare” visit that you can make an appointment for when you are first enrolled in Part B. This involves a conversation with your doctor about your healthcare needs and concerns. The second is your Annual Wellness Visit (AWV). The Medicare AWV 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 are your preventative vaccines (like annual flu shots). Be aware that some vaccines that are not considered typical preventative measures are not included under Part B. For example, the Shingles vaccine would be included under your Part D (prescription drug) coverage instead of Part B.
For people at risk, preventative services related to high blood pressure, high blood sugar, abnormal cholesterol, and obesity are also available at no cost. The same goes for those at risk for glaucoma, depression, cardiovascular disease, HIV, smoking and alcohol cessation, and various cancers.
Additionally, all women with Part B have 100% coverage for pap smears, pelvic exams, and breast exams every two years. If you are considered at-risk for gynecological conditions, you may be able to receive screenings every year instead.
While Medicare Part A will be responsible for inpatient mental health care, Part B covers outpatient mental health services.* Outpatient mental health coverage includes:
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.
*If you or a loved one is in immediate crisis, call the National Suicide Prevention Lifeline NOW at 1-800-273-8255 (TTY 1-800-799-4889), available 24-7.
Your doctor may order a lab test to help diagnose a condition or even as part of your annual checkup to be sure that your levels are where they should be. Medicare Part B covers medically necessary blood tests and other diagnostics sent to a lab at no cost to you. This includes blood work*, urine tests, tissue lab work, and some screenings.
Doctors may order x-rays to look for ailments that may be difficult to diagnose without seeing what is actually happening inside your body. While there are hundreds of reasons for x-rays, doctors are most likely to order an x-ray to check for heart failure, tuberculosis, pneumonia, fibrosis, or problems related to a surgery or treatment. Part B covers x-rays at 80% of the Medicare-approved amount, meaning you may be responsible for the other 20%.
*Blood for transfusions is handled a bit differently. If you are able to get transfusion blood through a donation, you may not have to pay anything. Otherwise, you may have to pay 20% of the Medicare-approved amount.
Part B can cover emergency transportation at 80% of the Medicare-approved amount, meaning that you would be responsible for 20%. Your Part B deductible will apply.
Medicare will only cover emergency transportation (ambulance) 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. Medicare will only cover air transportation if you need to get to a facility quickly and cannot do so by ground transportation (for example, if there is heavy traffic or another obstacle on the ground).
In some unique cases, Medicare 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. To access this service, do not call 911. Instead, 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 but can reach out to Medicare to request authorization for coverage. You can find a local non-emergency ambulance transportation company by searching your local yellow pages or running a Google Search.
Part B will only cover medical equipment if it is deemed durable. 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. You will pay 20% of the Medicare-approved amount. In some cases, you will not be given the choice, but you may be able to choose whether you want to rent or purchase the equipment you need. DME includes but is not limited to:
For Part B, you’ll need to meet a deductible of $185 per year before your coverage kicks in. Then, you’ll only have to pay 20% of the Medicare-approved amount for eligible medical services. Yearly wellness visits are almost always free with Part B.
Every beneficiary will have a Part B premium. You will receive a bill each month. If you receive Social Security or Railroad benefits, your Part B premium will be automatically deducted from your monthly benefit payments.
Most beneficiaries will pay the same standard premium amount ($135.50 in 2019), but if you have a high gross income, you will have to pay an IRMAA (Income-Related Monthly Adjustment Amount):
If you receive Social Security or Railroad benefits, you’ll automatically be enrolled in Part B. If you do not receive those benefits, you’ll need to sign up during your IEP (Initial Enrollment Period), which runs from three months before you turn 65 to three months after. If you do not enroll during your IEP, you’ll have to wait for the General Enrollment Period (Jan 1 - March 31) and will have to pay a late enrollment penalty fee. To enroll in Part B, go to SocialSecurity.gov or call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
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