Medicare Part B Coverage
Original Medicare is framed in two parts:
- Medicare Part A: hospital insurance
- Medicare Part B: medical insurance
Medicare Part B covers medically necessary services, including:
- Medical services in your doctor’s office and the hospital
- Outpatient care, including surgical procedures
- Home health services (some services covered under Part A)
- Durable medical equipment (DME)
- Mental health services
- Specific preventive services
What does Medicare Part B cover?
Medicare Part B covers doctor visits for many types of medical services. For most of these visits, your share of the cost will be:
- Coinsurance: 20% of Medicare-approved amount
- Part B deductible: $203 in 2021
Medicare Part B is the outpatient benefit, and it is used most often to cover expenses related to doctor visits and outpatient care. Medicare Part B benefits also apply toward clinical treatment as well as diagnostic testing and lab work. Additionally, outpatient surgery is covered by Medicare Part B if the procedure takes place in the outpatient department of a hospital. Home health services may also be billed to Medicare Part B if the service provider is not being supplied by a hospital or skilled nursing facility. Part B also includes a wide range of preventive services including cancer screenings, vaccinations, and annual wellness visits.
If you are prescribed durable medical equipment (DME), Medicare benefits may pay for the rental or purchase of your items depending on the medical necessity of the equipment. In virtually all cases, covered DME must be prescribed by a Medicare-participating physician and be obtained through a Medicare-approved distributor in order to qualify for coverage.
In terms of cost, Medicare Part B is optional coverage that requires a monthly premium payment. Most people enroll in Part B when they are first eligible to avoid late enrollment penalties later on. Additionally, Part B includes a deductible that must be met prior to benefits applying toward care. Finally, Medicare splits the cost of Part B services, paying 80% toward these costs while leaving the remaining 20% for you to pick up.
Preventive Care with Part B
Medicare Part B covers certain screenings and preventive doctor visits that do not require cost sharing if you use a provider that accepts assignment. By accepting assignment, your doctor agrees to accept direct payment of the Medicare-approved amount as payment in full, aside from any deductible or coinsurance for which you are responsible.
Examples of screenings:
- Mammogram every 12 months for women age 40 and older (baseline covered for women between ages 35 and 39)
- Pap tests and pelvic exams every 24 months as a standard (more often in certain circumstances)
- Colorectal cancer screenings (time frame depends on the type of screening)
Preventive and wellness:
- Welcome to Medicare preventive visit
- Yearly wellness visit
Welcome to Medicare
When you first join Medicare Part B, you are entitled to a Welcome to Medicare preventive visit. Though this visit does not include a physical exam, it does include:
- Review of your health and health-related social history
- Advice on preventative measures you can take, such as screenings
- Counseling on vaccinations
- Referrals, if needed
When you schedule your Welcome to Medicare preventive visit, be sure to let your doctor’s office know the purpose of the appointment. If the doctor performs a routine physical, you may be responsible for the total cost of the visit.
Yearly wellness visit
Twelve months after you enroll in Medicare Part B, you are eligible for an annual wellness visit. Having a Welcome to Medicare preventive visit is not a prerequisite to having a yearly wellness visit.
During this visit, your doctor can:
- Ask you to complete a health risk assessment
- Develop or update a customized plan to prevent disease or disability
- Perform a cognitive impairment assessment to detect signs of Alzheimer’s disease, dementia, depression and mood disorders.
What to expect from Medicare Advantage plans
Medicare Advantage (MA) plans are required to provide the same Part A and Part B benefits as Original Medicare. Most plans offer benefits that extend beyond Medicare Part A and Medicare Part B, such as vision and dental care, hearing exams and hearing aids, fitness programs, and prescription drug coverage. If you are enrolled in a Medicare Advantage plan, MA review your Evidence of Coverage or call your plan directly for specific information.