Medicare Part B is an optional Medical Insurance that has premiums and deductibles. Medicare Part B has traditionally covered physician services (doctor visits), outpatient hospital services, durable medical equipment/supplies, ambulance, dialysis costs, home health, x-rays, lab tests, outpatient physical therapy, vaccines, etc.
Part B covers some preventive services as well as medically necessary services. Medicare Part B generally pays only 80% of the approved fee, leaving the individual responsible for the remaining 20%, unless the individual has additional coverage (such as Medical Assistance or a Medicare Supplement (Medigap) policy). Although Medicare Part B is optional, if individuals decline coverage when they are eligible, there are serious consequences of such action.
These consequences limit when and how Part B coverage can be later obtained. Declining Part B coverage is a serious issue and individuals who are considering this step should not do so lightly or without individual advice from an advocate. There is both a significant financial penalty in the form of higher monthly premiums and a time limit on when individuals can re-enroll in Part B if they previously declined coverage
Many times individuals decline Part B coverage on the basis that they cannot afford the monthly premiums, when in fact those individuals qualify to have the premium paid for them by the Department of Human Services under one of the cost-sharing programs. Eligibility for the cost-sharing programs is set out in the Healthy Horizons sections of this handbook at Sections 319.1, 319.8, 319.9, Appendix A, B C in Chapter 388, Buy-In.
Individuals can choose to have Medicare in the traditional fee for service manner, or they can sign up with a Medicare Managed Care Plan. These managed care plans will have their own fees and cost sharing requirements.
Examples of covered services include:
Physician services.
Lab tests.
Outpatient hospital services.
X-rays.
Durable medical equipment.
Ambulance services.
Medication administered in a doctor’s office (i.e. chemotherapy).
Examples of covered, preventative services include:
A one-time “Welcome to Medicare” physical exam for new enrollees.
Colorectal cancer screenings.
Annual mammogram (for women 40 or older).
A pap smear and pelvic exam every two years (annually for those in certain high risk situations).
Annual prostate screening (for men age 50 or older).
Examples of items and services not covered by Medicare Part B:
Acupuncture.
Chiropractic services.
Cosmetic surgery.
Custodial Care.
Deductibles and co-pays.
Dental care and dentures.
Eye care.
Hearing aids, exams and fittings.
Medical transportation.
Long Term Care.
Orthopedic shoes.
Physical exams (routine or yearly).
Routine wellness visits.
Prescription drugs.
Routine eye exams and eyeglasses (except following cataract surgery).
Outpatient prescription drugs (with certain exceptions for immune suppressants and medication administered through IV or nebulizer).
Medicare beneficiaries who choose Part B must pay a monthly premium for the coverage which is typically automatically deducted from their Social Security benefits. Some individuals may have Part B premiums paid for them by MA. This is known as the Medicare Savings Program (MSP). See Section 388.3. Eligibility for the cost-sharing programs is outlined in the Healthy Horizons sections of this handbook at Sections 319.1, 319.8, 319.9, Appendix A, B and C and in Chapter 388, Buy-In.
Most individuals will pay a monthly premium of $104.90 in 2016. No change in premium from 2015 of $104.90
Individuals who currently have the SSA withhold their Part B premium and have incomes of $85,000 or less (or $170,000 or less for joint filers) will not have an increase in their premium in 2015. For all others, the standard Medicare Part B monthly premium is $104.90 in 2016. No premium change from 2015 of $104.90.
However, the monthly premium will be higher if an individual is single (file an individual tax return) and yearly income is more than $85,000, or if married (file a joint return) and yearly income is more than $170,000. The annual deductible for 2016 is $166.00. The annual deductible for 2015 is $147.00. The cost of the Part B premium and deductible may change every year in January.
The enrollment period for Part B is January through March to be effective July 1st of the same year.
Updated April 4, 2016 Replacing December 15, 2014