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This article is the second in a series examining what Medicare does and does not cover and why Medicare participants need additional coverage, through either Medigap policies or Medicare Advantage. This week’s article will address Part B which, in general, pays for outpatient medical services.
When to Enroll in Medicare Part B
Individuals who are receiving Social Security benefits or Railroad Retirement benefits are automatically enrolled in Medicare Part A and Part B. The Initial Enrollment Period (IEP) is 7 months, beginning 3 months before and ending 3 months after turning 65. If not automatically enrolled in Part B, it is best to enroll in the 3 months before turning 65. Enrolling in the last 4 months of the IEP will result in benefits being delayed.
Those not enrolled in Part B during the IEP must wait to enroll until the following open enrollment period from January 1 through March 31. Delaying enrollment increases the premium for Part B by 10% for each 12 months of delay.
This penalty is designed to prevent persons from entering the system only after incurring serious health issues. Obviously, if large numbers followed this course without penalty, the system would be bankrupted.
What is the Premium for Medicare Part B?
Premiums for Medicare Part B differ according to income. The monthly premium increments for those filing individual tax return are as follows: (1) $104.90 with annual income of $85,000.00 or less; (2) $146.90 with annual income of $85,000.01 to $107,000.00; (3) $209.80 with annual income of $107,000.01 to $160,000.00; (4) $272.70 with annual income of $160,000.01 to $214,000.00 and (5) $335.70 with annual income above $214,000.00.
The monthly premium increments for couples filing jointly are as follows: (1) $104.90 with annual income of $170,000.00 or less; (2) $146.90 with annual income of $170,000.01 to $214,000.00; (3) $209.80 with annual income of $214,000.01 to $320,000.00; (4) $272.70 with annual income of $320,000.01 to $428,000.00 and (5) $335.70 with annual income above $428,000.00.
What Services Does Medicare Part B Cover?
Medicare Part B pays for medically necessary outpatient services, including outpatient doctor services and some doctor services during hospitalization. If the doctor accepts assignment of Medicare, the patient pays, after meeting a deductible (which for 2015 is $147.00), the insured pays for 20% of the amount Medicare approves for the service.
Part B pays for certain preventive services to which no deductible applies. These preventive services come at no cost to the insured as long as the provider accepts assignment from Medicare. Among these preventative services are a “Welcome to Medicare” preventative doctor visit and an annual wellness visit.
If a referral for an abdominal aortic aneurysm screening is made at the Welcome to Medicare screening, Medicare pays for it. Other wellness services include alcohol misuse screening and counseling, behavioral therapy for cardiovascular disease, bone mass measurement, cardiovascular disease screening, colorectal cancer screenings, depression screening, diabetes screenings, diabetes self-management training, flu shots, glaucoma tests, Hepatitis B short, HIV screening, screening mammograms, obesity screening and counseling, Pap test, pelvic exam, and clinical breast exam, pneumococcal pneumonia shot, prostate cancer screening, sexually transmitted infection (STI) screening and high-intensity behavioral counseling to prevent STIs and smoking cessation therapy.
Outpatient Medical and Surgical Services and Supplies
Approved procedures like X-rays, casts or stitches are covered by Part B. However, these are subject to the annual deductible, with the patient, after deductible, paying the doctor 20% of the Medicare-approved amount if the doctor accepts assignment. The patient also pays the hospital a copayment for each service provided.
Durable Medical Equipment
Items such as oxygen equipment and supplies, wheelchairs, walker, and hospital beds for home use are covered but are also subject to the deductible.
Medicare is phasing in a program of “competitive bidding” for durable medical equipment, meaning that, in some areas, an insured must use certain suppliers to provide the medical equipment. The website at www.medicare.gov/supplier provides the Medicare-approved suppliers in a given area.
Home Health Care Services
Although Medicare Part A pays for some home health care services, some are included in Part B covered. Those services that are covered are covered 100%. The services must be medically necessary part-time or intermittent skilled nursing care and/or physical therapy, speech-language pathology services, and/or continuing occupational therapy. Some home health aide, medical social services and medical supplies are also covered.
Other Medically Necessary Services and Supplies
Clinical laboratory services, diabetes supplies, kidney dialysis serves and supplies, mental health care, limited outpatient prescription drugs, diagnostic X-rays, MRIs, CT scans, and EKFs, transplants and other services are covered but costs for these may vary.-
What Services Does Medicare Part B Not Cover?
Part B does not pay for 24 hour skilled home health care, home delivery of meals, homemaker services or personal care. It will not pay for long-term care skilled nursing home care. Nor does it cover routine dental care or dentures. Hearing examinations and hearing aids are not paid for by Part B. As you would expect, Medicare will not pay for a fact lift or any other cosmetic surgery.
Medicare Part B may not cover all the diagnostic tests that a doctor orders. That means that the patient would bear the cost of these tests. For that reason alone, it is important to explore the options provided by a Medigap policy or Medicare Advantage plan which may pay for testing not covered under original Medicare.
Sandra W. Reed is an attorney with Katten & Benson, an Elder Law firm in Fort Worth, Texas. She lives in beautiful Somervell County, near Chalk Mountain. If you have questions about this column or wish to suggest a topic of interest, Ms Reed may be contacted by phone at 254.797.0211 or by email at firstname.lastname@example.org.