Original Medicare: Part B
Part B of Original Medicare helps cover medically-necessary services such as for doctors, outpatient care, home health care, durable medical equipment, and others.
Original Medicare: What is Covered and What You or Your Senior Loved One is Responsible ForWhat You
Pay for Part B‑Covered Services:
Medicare beneficiaries must typically pay all costs until the yearly Part B deductible is met ($140 in 2012) before Medicare begins to pay its share. Then you usually pay 20% of the Medicare-approved amount of the service, if the doctor or other health care provider accepts assignment (assignment means he/she is approved and agrees to accept the Medicare fee schedule and conditions). There is no yearly limit for what you pay out-of-pocket.
You or your senior loved one would typically be responsible for 20% of the Medicare-approved amount, and the Part B deductible would apply for all of the following services unless otherwise noted:
Ambulance Services – When necessary and only to the nearest medical facility.
Ambulatory Surgical Centers – Where surgical procedures are performed and the patient is released within 24 hours.
Cardiac Rehabilitation – In a doctor’s office. If in a hospital outpatient setting, you also pay the hospital copayment.
Chemotherapy – In a doctor’s office, freestanding clinic, or hospital outpatient setting. If in a hospital inpatient setting, it’s covered under Part A Hospital Care.
Chiropractic Services – Limited to only helping correct a subluxation (when one or more of the bones of your spine move out of position) using manipulation of the spine.
Clinical Research Studies – Upon approval.
Diabetes Supplies – (Medicare only covers insulin if used with an external insulin pump.)
Doctor and Other Health Care Provider Services (except for certain preventive services) – Includes outpatient and some doctor services received as an inpatient.
Durable Medical Equipment – Such as walkers, oxygen equipment and wheelchairs.
Emergency Department Services.
Eyeglasses – Limited to one pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens.
Foot Exams and Treatment – Covered if you have diabetes related nerve damage and meet certain conditions. You also pay the hospital a copayment, if applicable.
Hearing and Balance Exams – Covered if ordered to see if you need medical treatment. If applicable, you also pay the hospital copayment. (Medicare doesn’t cover hearing aids or exams for fitting them.)
Kidney Dialysis Services and Supplies – Generally, Medicare covers dialysis treatment three times a week if you have End-Stage Renal Disease (ESRD).
Kidney Disease Education Services – Up to six sessions of kidney disease education services if you have Stage IV kidney disease.
Occupational Therapy – Within limits.
Physical Therapy – Within limits.
Prescription Drugs – Within limits – typically injections you get in a doctor’s office, certain oral cancer drugs, drugs used with some types of durable medical equipment (like a nebulizer or external infusion pump), and under very limited circumstances, certain drugs you get in a hospital outpatient setting. The rest are covered by Medicare Part D.
Prosthetic/Orthotic Items – By a supplier that’s enrolled in Medicare.
Pulmonary Rehabilitation – You also pay the hospital a copayment, if applicable.
Second Surgical Opinions – When approved.
Speech-Language Pathology Services – Within limits
Tobacco Use Cessation Counseling – Within limits
Telehealth – Limited to within approved medical facilities and certain circumstances.
Transplants and Immunosuppressive Drugs
Travel – When traveling outside the United States – very limited to certain circumstances and emergencies.
Urgently-Needed Care – If applicable, you would also pay the hospital copayment.
Defibrillator (Implantable Automatic) – You also pay the hospital copayment, if applicable, but no more than the Part A hospital-stay deductible. (Surgeries to implant defibrillators in a hospital inpatient setting are covered under Part A.)
Outpatient Hospital Services – You will usually pay the hospital a copayment if applicable, but it can’t be more than the Part A hospital-stay deductible.
EKG (Electrocardiogram) Screening – (unless part of your one-time “Welcome to Medicare” preventive visit): If you have the test at a hospital or a hospital owned clinic, you also pay the hospital copayment.
Tests (other than lab) – If at a hospital as an outpatient, you also pay the hospital copayment but it can’t be more than the Part A hospital-stay deductible.
Outpatient Medical and Surgical Services and Supplies – you will usually also pay the hospital copayment, but it can’t be more than the Part A hospital-stay deductible.
Surgical Dressing Services – You pay a fixed copayment for these services when you get them in a hospital outpatient setting. You pay nothing for the supplies.
Mental Health Care (outpatient) – Generally, you pay 40% which will decrease until it reaches 20% in 2014. The Part B deductible applies for both visits to diagnose or treat your condition.
Blood – Same as Part A for first 3 units.
Rural Health Clinic Services – You pay nothing for most preventive services.
Federally-Qualified Health Center Services – You pay nothing for most preventive services.
Home Health Services – You pay nothing for covered home health services.
Laboratory Services – You pay nothing for these services.
To find out if Medicare covers a service not on this list, visit www.medicare.gov/coverage or call 1-800-MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048. For more details about Medicare‑covered services, visit www.medicare.gov/publications to view the booklet “Your Medicare Benefits.”
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Gary Phillips is a licensed insurance agent based in western North Carolina. He specializes in the senior market and is knowledgeable in multiple insurance lines including Medicare, Medigap, Long-Term Care, Part D Prescription Drugs, Part C Medicare Advantage, Health, Life and Final Expense insurance. He also enjoys writing and helping others. www.bizpartner.homestead.com
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Information contained in this article is presumed accurate at the date of publication (06/2012), but not guaranteed. In addition, Medicare changes rules and costs annually so it’s important to refer to the paragraph above to access the most current data.