Medicare Parts A & B are known as the Original Medicare. Together they are said to serve as the foundation of an eligible individual's Medicare coverage.
In a separate blog post, we’ve walked you through the details of Part A, which covers most inpatient services in addition to hospital and home nursing care. Part B of the program looks after a very different side of an individual's healthcare needs, which is medical insurance that covers a broad range of services including outpatient care, doctor visits, x-rays, emergency care, ambulance transportation, IV medications, labs, MRI, other durable medical equipment. It also includes preventive services such as screenings and vaccines.
Yet the services and items covered are not the only things that differentiate Part B from A -- there are also major differences in costs to Medicare members. In this blog post -- the second in a series that seeks to explain the different parts of Medicare coverage -- we will walk you through all the details about Part B. But first, let us briefly recap the basics of Medicare.
What is Medicare and Who are Eligible for Medicare Enrollment?
Medicare is the federal health insurance program for people who are 65 or older, younger people with certain disabilities, and people with permanent kidney failure who requires dialysis or a transplant(a condition also known as end stage renal disease). The areas of coverage under the four parts of Medicare include the following:
- Medicare Part A: Hospital Insurance -- covers all inpatient hospital stays, care in skilled nursing facilities, hospice care, and some home health care
- Medicare Part B: Medical Insurance -- covers some doctors' services, outpatient and preventive care, and medical supplies
- Medicare Part C: Medicare Advantage Plan -- the private health insurance alternative to the original Medicare
- Medicare Part D: Prescription drug coverage -- covers the cost of prescription drugs, recommended shots and vaccines.
The cost for Medicare coverage may vary depending on the kind of coverage and services you get, and also the medical service providers you visit.
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Medicare Premiums for Part B
The standard Medicare Part B monthly premium in 2023 is $164..90. This premium level may change every year, and you will have to pay the full premium each month even if you are not getting any services covered by Part B. If you have a higher income, you will pay an income related adjusted amount based on your IRS tax return from two years ago. You will pay higher premiums if your modified adjusted gross income is more than:
- $97,000 in 2023, if you file an individual tax return or are married and file separately
- $194,000 in 2023, if you are married and file a joint tax return
Th monthly premiums for Medicare Part B can go up to as high as $560.50 (for those with gross income of $500,000 and filing individually, and $750,000 if filing jointly).
Contact the Social Security office to find out if you have to pay a higher premium because of your income. You can also ask them to lower the additional amount you have to pay if you have had a life-changing event that reduced your household income. These events include marriage, divorce, death of a spouse, loss of income, and an employer settlement payment.
How is the Premium for Medicare Part A Compared with Part B?
As explained in the last blog, many people get Part A for free. The easiest way to qualify for free Part A Medicare is with age -- you are automatically eligible when you turn 65 and have paid Medicare taxes for a certain period of your working life. In fact, if you fail to enroll during the Initial Enrollment Period you face a penalty when you do eventually enroll.
Part A is also free for those who are recipients of retirement benefits through Social Security or the Railroad Retirement Board. If you want more detail, contact Social Security. If you do not qualify for free Part A, your monthly premium of $278 or $506 (2022 levels) is determined by how long you or your spouse had worked and paid Medicare taxes.
For most people, when they buy Part A, they must also get Part B. Yet Part B can be purchased independently of Part A, and some people who don't choose to get Part A can also buy Part B. A penalty maybe imposed on you if you don't get Part B when you are eligible, and the amount is about 10% extra for every 12-month period that you failed to sign up after you become eligible.
Medicare Part B Premiums for Members with Low Income
Unlike Part A, Part B is only free for those with low income and those who are enrolled in one of the Medicare Savings Programs for financial assistance. The eligibility for these programs for different for each state. Some states would make it easier to qualify by setting higher income limits or by eliminating the asset requirement.
What does Medicare Part B cover?
Two types of services are covered by Part B: medically necessary services and preventive services.
Medically Necessary Services:
These are services or supplies that are needed to diagnose or treat your condition which meet accepted standards of medical practice
Preventive Services
These are services to prevent illness (COVID, Flu) or detect them at early stages when treatment is most likely to work best.
The cost to you are normally zero if you are getting preventive services from a healthcare provider who accept assignment, which is an agreement between your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance.
Some of the other services covered by Part B include the following:
Ambulance Services
Part B also covers ground ambulance transportation if your health may be endangered by traveling in any other vehicles and you need to obtain necessary care from a hospital or skilled nursing facility.
In fact, Medicare may even pay for emergency ambulance transportation in an airplane or helicopter if you need immediate and rapid transport that ground transportation can’t provide.
In some cases, Medicare may pay for limited, medically necessary but non-emergency ambulance transportation if you your doctor stated in written order that the transportation is medically necessary, such as if you have end stage renal disease and needs to be taken to a kidney dialysis facility.
Durable Medical Equipment (DME)
Part B covers medically necessary DME when a Medicare-enrolled doctor or healthcare provider order them to be used in your home. These equipment include but are not limited to blood sugar meters, and test strips, canes, commode chairs, crutches, hospital beds, infusion pumps & supplies, oxygen equipment and accessories, suction pumps, walkers, wheelchairs, and scooters.
Medicare pays for DMEs in different ways, and you may rent or buy the equipment depending on their types.
Mental Health Care
Part B pays for outpatient mental health services including depression screening, psychotherapy with doctors, family counseling, psychiatric evaluation, and certain prescription drugs as well as tests and partial hospitalization.
It also covers outpatient mental health services for substance abuse treatment. /
What's Not Covered
There are a few things that neither Part A nor Part B cover and they will have to be paid by yourself. The list include:
- Long-Term Care (also called custodial care)
- Most dental care
- Eye exams (for prescription glasses)
- Dentures
- Cosmetic surgery
- Massage therapy
- Routine physical exams
- Hearing aids and exams for fitting them
- Concierge care (also called concierge medicine, retainer-based medicine, boutique medicine, platinum practice, or direct care)
- Covered items or services you get from an opt-out doctor or other provider (except in the case of an emergency or urgent need)
To find out if Medicare covers what you need, talk to your doctor or other health care provider about why you need certain services or supplies. You can also ask them if Medicare will cover these items.
Sometimes, you may require services that's usually covered but your doctors may think that Medicare won't cover it. If that is the case, you will have to read and sign a notice that says that you may have to pay for the service, supply, or item out of your own wallet.
Medicare Part B Deductibles and Coinsurance
For most of the Part B-covered services mentioned above, you usually pay 20% of the Medicare-covered services or item after you meet your deductible. This amount is called your coinsurance
In 2023, the annual deductible for all Part B members is $226, which is down from the $233 in 2022.
Initial Enrollment Period (IEP)
Similar to Part A, Part B's Enrollments are handled by the Social Security Administration. You can sign up at your local social security office or online at SSA.gov. Bear in mind that there may be penalty if you fail to enroll in Medicare on time.
The first sign up window is when you turn 65. The initial enrollment period lasts for seven months -- it starts three months before your birthday month and ends three months after that. So if your birthday is on March 10, you initial enrollment period is from December 1st until June 30th. For Part B, the coverage starts based on the month you sign up.
If you miss this window, you can only sign up for Part B and premium-Part A during one of the other enrollment period. For example, you will get another chance that's known as the general enrollment period. And this lasts from January 1st to March 31st of each year. So while Part A is still premium-free, since you have missed the first enrollment period, you will likely have to pay higher monthly premium for Part B.
Special Enrollment Period (SEP)
There are certain situations when you can sign up for Part B (and Premium-Part A) during a Special Enrollment Period (SEP) without paying a late enrollment penalty. For example, if you have been impacted by a disaster or an emergency,
An SEP is only available for a limited time. If you don’t sign up during your SEP, you’ll have to wait for the next General Enrollment Period and you might have to pay a monthly late enrollment penalty.
If you want to sign up for one of these SEP, fill out Form CMS-10797 (Application for Medicare Part A and Part B Special Enrollment Period). Send the completed form to your local Social Security office by fax or mail.
Medicare Part B Late Enrollment Penalty
As mentioned above, if you fail to sign up for Medicare coverage during your Initial Enrollment Period, you may have to pay an extra amount called a late enrollment penalty. The only exception is if you have other coverage that's similar in value to Medicare, such as an employment-linked health coverage.
Late enrollment penalties are not a one-time late fee and may be added to your monthly premium. This means they are are usually charged for as long as you have the coverage. The amount also increase the longer you wait to sign up for Medicare.
How Medicare Works with Other Coverage
If you are concerned about the cost of deductibles and copayments, you need not worry. Many insurance providers offer plans that either help reduce your out-of-pocket expenses under Medicare or expand coverage to services that are not covered by the program.
EASY Insurance Plans, is dedicated to finding the right Medicare plan for you. Our experts are available to provide answers and will not rest until your health care needs have been met. Best of all? Our services come at no cost to you! Let us help make sure that you get the coverage that best fits your situation - contact us today!