What is Medicare Part B?
Medicare is the federal health insurance program designed for people age 65 and older or for people under the age of 65 with certain illnesses or disabilities.
Medicare Part B is Medical Insurance and is a core part of Medicare that covers outpatient medical services and supplies as well as certain preventative services. When combined with Medicare Part A (Hospital Insurance), the two are commonly referred to together as ‘Original Medicare’.
Am I eligible for Medicare Part B?
To be eligible for Medicare Part B you must be 65 or older and you must be a U.S. citizen or a permanent resident that has been in the U.S. continuously for 5 years.
If you are eligible for Medicare Part B, you will be required to pay the standard Part B premium in order to enroll in Part B.
In 2021, the standard Part B premium is $148.50 per month (vs. $144.60), however, your premium may be higher depending on your income level. You will also have an annual deductible of $203 (vs. $198 in 2020) before Part B insurance kicks in.
If you are under the age of 65 you may also be qualified for Medicare Part B if you have a disability. If you have you are under 65 and have been receiving Social Security disability benefits for at least 24 months you will be automatically enrolled in Part A and B of Medicare. You are also eligible if you have End-Stage Renal Disease (‘ESRD’) (permanent kidney failure) or Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease.
What is covered by Medicare Part B?
Medicare Part B covers medically necessary outpatient services or supplies as well as certain preventive services.
Medicare Part B will cover your doctor visits and the services and supplies that are used by your doctor during outpatient visits. Part B will also cover emergency room and hospital visits where you are not officially admitted as an ‘inpatient’ by a doctor (this could include overnight observations).
Ambulance related services including ground ambulance transportation to a hospital or skilled nursing facilities for medically necessary services are covered by Part B. Alternative ambulance transportation like airplanes or helicopters may also be covered if rapid transportation is needed. Medicare will only cover ambulance services to the nearest appropriate medical facility that’s able to give you the care you need.
Durable Medical Equipment (DME)
Medicare Part B also covers any necessary durable medical equipment which is any medical equipment your doctor has prescribed for you to use at home. For example, DME may include blood sugar monitors/tests, crutches, patient lifts, hospital beds, walkers, wheelchairs, pumps, nebulizers or other equipment that is typically not useful for someone who isn’t sick or injured. Medicare pays for different kinds of DME in different ways and depending on the type of equipment you may be required to either rent or buy them.
Mental Health Services
Medicare Part B provides some coverage for outpatient mental health services. Part B covers one free depression screening a year and will also help pay for psychotherapy, family counseling, psychiatric evaluations, medication management, diagnostic tests and certain drugs that aren’t self-administered. Inpatient mental health care will generally be covered under Part A.
Limited Prescription Drugs
Under limited circumstances and conditions, Part B will also cover prescription drug costs. Coverage is typically for drugs you wouldn’t administer yourself, like those you get at a doctor’s office or hospital outpatient setting. These drugs include injectable and infused drugs given by a medical professional, antigens and drugs used with DME.
Clinical research studies (also called clinical trials) help doctors and researchers test how well different types of medical care work and if they’re safe. You may have the choice to join a clinical research study to diagnose or treat an illness. Medicare covers certain clinical research studies and may help pay for some of your costs if you decide to participate.
In most cases you will need to pay nothing for preventative services if you get the services from a health care provider who accepts assignment. Typical preventative services include flu shots as well as cancer, depression, HIV, diabetes, bone mass and cardiovascular-related screenings. The full list can be found at this link: Medicare Preventive Screening Services.
In addition, you are also eligible for a free “Welcome to Medicare” preventive visit within the first 12 months you have Part B as well as a free “Annual Wellness Visit” to develop or update a personalized prevention plan based on your current health and risk factors.
What is NOT covered by Medicare Part B?
Part B only covers medically-necessary services. The following services are typically not included because they are considered non-medically essential such as:
Routine Vision, Hearing, Dental and Foot Care
Routine services for vision, hearing, dental and foot care are not covered by Medicare. For example, vision checkups, eyeglasses, hearing aids, dental checkups and dentures will generally not be covered by Medicare. However, if a patient has something that is medically necessary such as cataract surgery, or jaw reconstruction then this will be covered.
Even so, you may be able to get vision, hearing and dental benefits if you choose to enroll in a Medicare Advantage (Part C) plan which is a private ‘all-in-one’ bundled alternative to Original Medicare.
Medicare will generally not cover any custodial care which includes non-skilled personal care such as help doing daily activities like getting up, moving around, dressing, eating, bathing and using the bathroom. Medicare will only cover skilled nursing care at a skilled nursing facility after a ‘qualifying hospital stay’ and if covered, will be covered under Part A.
Home safety items are not covered except in very limited circumstances when deemed medically necessary by a doctor. Home safety items include grab bars, stairlifts, bathtub seats, or medical emergency systems.
Elective Cosmetic Procedures
Part B does not cover any elective cosmetic procedures, these are not considered medically necessary. Medicare will cover trauma / accident-related procedures. These will generally be covered under Part A as most medically necessary procedures will likely be in an inpatient setting.
Fitness & Wellness
Medicare does not cover fitness programs or alternative medicines. However, you may be able to access some fitness benefits through a Medicare Advantage plan (Part C).
Do I need to be enrolled in Medicare Part B?
Part B is one of the most important components of your health insurance when you are receiving health coverage from Medicare and similar to Part A, there are Late Enrollment Penalties if you do not enroll when you are first eligible.
If you are turning 65, it is recommended that you enroll into both Medicare Part A and B during your Initial Enrollment Period to avoid any penalties if any of these situations apply to you:
- You get health insurance from you or your spouse’s employer and that employer has fewer than 20 employees
- You are currently using COBRA or retiree insurance from a previous job
- You are enrolled in an individual health insurance plan such as an ACA plan
- You rely on short-term insurance or have no insurance at all
- You have VA health coverage
- You have TRICARE coverage and are retired
You may choose to delay enrollment in Part B if you are still working. In order to do this, you must have qualifying coverage through your (or your spouse’s) employer. If you qualify you will also not be charged any penalty for delaying enrollment. You may qualify for deferral if the employer providing coverage has greater than 20 employees.
Part B: Late Enrollment Penalties
If you didn’t get Part B when you’re first eligible, your monthly premium may go up 10% for each 12-month period you could’ve had Part B, but didn’t sign up.
The penalty increases the longer you go without Part B coverage and in most cases, you’ll have to pay this penalty each time you pay your premiums, for as long as you have Part B.
Part B: Pre-requisite Enrollment for Medicare Advantage and Medicare Supplement
Enrollment in Part B is a prerequisite when applying to enroll in Medicare Advantage (Part C) plan or Medicare Supplement (also known as ‘Medigap’). If you want to enroll in either of these types of plans you must first be enrolled in both Medicare Part A and B.
How much is Medicare Part B?
Outlined below are the costs of Medicare Part B under Original Medicare. If you choose to receive or supplement your Medicare coverage through private health insurance plans such as Medicare Advantage or purchase a Medicare Supplement plan (also known as ‘Medigap’) the costs may vary or change in accordance with the policy’s stated benefits.
Part B: Premiums
Everyone who enrolls in Part B must pay a premium. This is different from Part A where many people are eligible to receive Part A coverage premium-free. Premiums for Part B are typically deducted from your Social Security payments. In 2021, the standard Part B premium amount is $148.50 per month.
Medicare beneficiaries who meet certain eligibility requirements for low income may be eligible to participate in a Medicare Savings Program (MSP) which is to help pay your Medicare premiums. To check if you are eligible for MSP you can call your State Medicaid Program to check.
If your income reported to the IRS is above a certain threshold, you may pay have to pay a higher Part B premium. This is known as an Income Related Monthly Adjustment Amount (IRMAA).
Medicare uses the modified adjusted gross income reported on your IRS tax return from 2 years ago as this is the most recent tax return information provided to Social Security by the IRS. For example, Social Security would use tax returns from 2019 to determine your IRMAA in 2021. If Social Security determines that you should pay an IRMAA, they will mail you a notice called an initial determination.
What if my income is no longer as high as it was 2 years ago?
A lot of things can happen in 2 years and the income reported to the IRS from a couple of years ago may longer reflect your current situation. What should you do in this situation if Social Security has determined that you need to pay an increased premium?
You can request that Social Security revisit its decision if you have experienced a ‘life-changing event’ that caused an income decrease, or if you think the income information Social Security used to determine your IRMAA was incorrect or outdated. Social Security considers any of the following situations to be life-changing events:
- You or your spouse stopping working or reduced the number of hours you work
- Loss of pension
- Involuntary loss of income-producing property due to a natural disaster, disease, fraud, or other circumstances
- The death of a spouse
- Marriage, divorce or annulment
- Receipt of settlement payment from a current or former employer due to the employer’s closure or bankruptcy
To request a review of your premium, you will need to fill out a Medicare IRMAA Life-Changing Event (Form SSA-44) and provide evidence of your life-changing event as well as your most recent tax return verifying your reduced income.
Part B: Out of Pocket Costs (Deductibles, Copays, Coinsurance)
In 2021, the annual deductible for Medicare Part B is $203. Once you have paid your deductible, Part B coverage will kick in and will pay 80% of the Medicare-eligible medical services and supplies.
You will be responsible for the remaining 20% out of pocket, in other words, you have a 20% coinsurance obligation for the remainder of the year.
Medicare Part B is the Medical Insurance that covers medically necessary outpatient services such as your doctor, emergency services and certain durable medical equipment. Unlike Part A, if you are enrolled in Part B you will need to pay the Part B premium. The premium is tied to your income filed with the IRS from 2 years ago. In 2020, the standard Part B premium is $148.50 and the annual deductible is $203. Part B has a 20% coinsurance obligation for all Medicare eligible services and supplies once you reach the deductible.