Medicare Part B: Coverage Explained

Medicare is governmental health insurance for those aged 65 or older or those with certain health conditions. Before enrolling in Medicare, it’s essential to understand the four main Medicare parts: A, B, C, and D and what they cover. In this article, we will discuss Medicare Part B, commonly known as medical insurance, which covers two main categories of care: preventive care and medically necessary services.

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Understanding Medicare Part B

According to The Centers for Medicare and Medicaid Services (CMS), Medicare Part B, medical insurance, is an optional part of Medicare that covers medically necessary services and select preventive services. Medically necessary services include things like doctor’s services, durable medical equipment (DME), ambulance services, outpatient services, telehealth, and clinical research studies. CMS maintains a list of services that are covered under Part B. The preventive services include things like flu shots, screenings for health issues, mammograms, and smoking cessation programs.

Medicare Part A, or hospital insurance, covers treatment at a medical facility like a hospital. It also covers inpatient stays at skilled nursing facilities or nursing homes and hospice or home health services. Even though it is not mandatory, Part B covers many essential medical services.

Medicare Part A and Part B are collectively known as Original Medicare. An alternate way to receive Parts A and B is to enroll in a Medicare Advantage Plan, which provides coverage through a private insurance company contracted to provide Medicare services. Also known as Part C, Medicare Advantage Plans provide all the services covered in Part A and Part B, and usually additional benefits like fitness programs and vision and dental coverage.

What does Medicare Part B cover?

Medicare Part B is medical insurance that covers a range of services. Although not all-inclusive, this list reviews many of the Part B covered services. Most of them require a doctor’s order to qualify as being medically necessary. Elective procedures or tests are not covered.

• Healthcare provider visits. Part B covers healthcare provider visits that could include your doctor or another healthcare provider, such as a nurse practitioner, physical therapist, marriage or family therapist, or a specialist, such as a cardiologist or podiatrist. Check with your doctor or healthcare provider if they accept Medicare before scheduling an appointment. If you have Medicare Advantage, you will need to check with your health insurer to see what doctors are in the network.
• Tests. Many clinical diagnostic laboratory tests such as bloodwork, X-rays, CT scan, MRI, or EKG are covered.
• Outpatient services. Outpatient surgery for a procedure that does not require an overnight stay at a medical facility. Medicare has a price lookup website where you can find out how much you can expect to pay by searching for the procedure. Outpatient services could also include physical, speech, or occupational therapy.
• Durable medical equipment. Medical supplies like walkers, wheelchairs, canes, devices to treat obstructive sleep apnea, braces, prostheses, or diabetes supplies like glucometers are some of the equipment covered.
• Ambulance services. If you need medical services at a hospital or skilled nursing facility, Part B will cover ground transportation via ambulance. Air transportation may be covered if ground transportation is not available. In some cases, scheduled ambulance services are covered if ordered by your doctor.
• Preventive care and screening services. Medicare Part B covers a wide range of preventive services, usually at 100%. These include the Annual Medicare Wellness Visit, advance care planning, screenings for diabetes, glaucoma, colorectal and breast cancer, flu, pneumococcal, COVID-19, and hepatitis B shots, educational programs for diabetes management and chronic care, and nutritional counseling for diabetics or those with kidney disease.

If you don’t see a particular service listed above that you need, check Medicare’s website to verify if your test or service is covered. Before scheduling medical appointments, it’s wise to verify if it will be covered and how much you could expect to pay in copayments or coinsurance.

Medicare Part B alone does not cover dental, vision, or hearing services.

How does Medicare Part B work?

Medicare Part B enrollment is optional. If you choose to enroll, you can do so at designated times throughout the year. The Initial Enrollment Period is your first opportunity to enroll in Medicare when you turn 65. If you delay enrollment, there are other opportunities to enroll, such as the Annual Enrollment Period or a Special Enrollment Period. You may enroll online, in person at your local Social Security office, or via phone. Check out this article for more details on when to apply for Medicare.

Even though it is optional, if you do not enroll when eligible and decide to enroll at a later date, you could be charged a late enrollment penalty. The penalty is an additional 10% for every year you were eligible to enroll but did not. This amount is added to your monthly premium for as long as you have Part B coverage. It is not a one-time fee. Read more about understanding late enrollment penalties here.

Additional considerations for Medicare Part B

There are ongoing costs charged for Part B coverage. You will pay a monthly premium to have Medicare Part B. Typically, the premium is a standard amount. You may pay more based on your income. The standard amount in 2024 is $174.70. The premium is paid monthly regardless of how much medical care you receive in that month. Additionally, a copayment or coinsurance is charged when you receive medical services. For example, a doctor's visit may incur a $20 copay that you would pay out-of-pocket.

The annual deductible for Medicare Part B in 2024 is $240. A deductible is the amount of money that you must pay out-of-pocket before Medicare will start to share in medical costs. The deductible resets every year.

Medicare Supplemental Insurance, known as Medigap, can help offset some of the out-of-pocket costs. Private insurance companies offer Medigap plans to fill in the gap for Original Medicare costs. They can help pay for deductibles, coinsurance, and copayments.

A Medicare specialist can help guide you in selecting a plan that meets your needs and budget. Each state offers free, unbiased guidance counselors via the State Health Insurance Assistance Program (SHIP). You can contact them at 1-877-839-2675 or visit your state’s SHIP website. The “Medicare and You” handbook is a comprehensive guide available on Medicare.gov and is mailed to your home each September. This guide covers Medicare topics such as enrollment, costs, health, and drug plans, and frequently asked questions.

Final words

Medicare Part B, medical insurance, covers medically necessary services and preventive services. Although optional, Part B covers many procedures, exams, healthcare equipment, and medical care that Part A does not cover. Enrolling during your Initial Enrollment Period is one of the most common times to enroll in Part B, but there are other enrollment periods available. Keep in mind that delaying enrollment could incur lifelong late penalties. Free resources are available to help you select the right health insurance plan for your needs and budget.