INSURANCE 101: Medicare Part B

Supplementary Medical Insurance (SMI)

Medicare Part B is a voluntary part of Medicare, providing benefits that coordinate with and cover certain expenses not covered under Part A.  Under Part B, an enrollee is required to pay an additional monthly premium to maintain Part B coverage.  Most enrollees pay the standard Part B premium amount, though based on income tax returns, some enrollees may pay a slightly higher premium.

In addition, late enrollment into Medicare Part B requires an enrollee to pay a 10% increase for each full 12-month period beyond age 65.  This means that an individual who waits until age 67 to enroll into Medicare Part B will pay a 20% increase in monthly premium (each full 12-month period = 10% penalty increase) over the initial enrollment period standard premium amount.

The following benefits are included under Medicare Part B coverage:

• Physician Services
• Covers services of physicians, surgeons, and osteopaths wherever treatment is administered, whether it is in a hospital, clinic, SNF, at the patient’s home, or anywhere else in the U.S.
• Services covered include medical and surgical services, office or hospital visits, house calls, x-rays, diagnostic testing, and medical supplies provided by the physician
• Preventive care

Approved vs. Non-Approved Physicians
When a physician accepts the Medicare approved amount as full payment, they have agreed to accept ‘assignment’ of the Medicare-approved amount, and cannot separately bill the patient for anything above that amount.  Most physicians accept a Medicare assignment, but if the provider requires actual amounts for services rendered instead of the reasonable amount prescribed by Medicare, the patient is responsible for paying the balance.

Non-participating providers haven’t signed an agreement to accept assignment for all Medicare-covered services, but they can still choose to accept assignment for individual services.

Providers who ‘opt-out’ of the Medicare program may still accept Medicare patients; however, physicians who opt-out are not required to follow Medicare laws and can charge any amount deemed necessary for their services.

Home Health Care (If not covered by Part A)
If Medicare Part A is not elected, and Part B is purchased alone, home health care will be covered 100% under Part B.  The enrollee is only required to cover 20% of any durable medical equipment such as a wheelchair or hospital bed.

Normally home health care is covered under Part A, but as an example: If an individual turned 65 but was not eligible for Social Security, Part A would not be free and the individual could elect not to purchase Part A and instead purchase Part B alone.  In this example, home health care would be covered under Part B.

Hospice Care (If not covered by Part A)
If an enrollee’s attending physician isn’t employed by the hospice, the enrollee can pay his or her usual Part B deductible and coinsurance for his or her services. If not covered by Part A, Part B will cover the physician’s services while the enrollee is in a hospital.

Outpatient Medical Services and Supplies

• Part B covers any outpatient services from a Medicare-certified hospital to diagnose or treat an illness or injury
• Part B also provides extensive coverage for outpatient services and supplies such as services for outpatient clinics, emergency rooms, x-rays, blood transfusions (after the first 3 pints), outpatient therapy (physical, occupational, speech), mammograms, pap smears, colorectal screenings, diabetes monitoring and education, and flu shots