Medicare Part B
Part B of Medicare is intended to fill some of the gaps in medical insurance coverage left under Part A. After the beneficiary meets the annual deductible, Part B will pay 80% of the "reasonable charge" for covered services, the reimbursement rate determined by Medicare; the beneficiary is responsible for the remaining 20% as "co-insurance." Unfortunately, the "reasonable charge" is often less than the provider's actual charge. If the provider agrees to "accept assignment," he agrees to accept Medicare's "reasonable charge" rate as payment in full and the patient is only responsible for the remaining 20%. If the provider does not accept assignment, the patient will be responsible for paying a portion of the difference between Medicare's reimbursement rate (the reasonable charge) and the provider's actual charge.
Since 1972, individuals receiving Social Security retirement benefits, individuals receiving Social Security disability benefits for 24 months, and individuals otherwise entitled to Medicare Part A, are automatically enrolled in Part B unless they decline coverage. Others must enroll in Part B by filing a request at the Social Security office during certain designated periods.
The major benefit under Part B is payment for physicians' services. In addition, home health care, durable medical equipment, outpatient physical therapy, x-ray and diagnostic tests are also covered. Since January 1, 1998 home care is covered under Part B if the individual does not meet the Part A prior institutional requirements, received coverage under Part A for the maximum annual 100 visits, or only has Part B.
The following is a list of items and services which can be covered under Part B:
- Physicians' services
- Home Health Care
- Services and supplies, including drugs and biologicals which cannot be self-administered, furnished incidental to physicians' services
- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests
- X-ray therapy, radium therapy and radioactive isotope therapy
- Surgical dressings, and splints, casts and other devices used for fractures and dislocations
- Durable medical equipment
- Prosthetic devices
- Braces, trusses, artificial limbs and eyes
- Ambulance services
- Some outpatient and ambulatory surgical services
- Some outpatient hospital services
- Some physical therapy services
- Some occupational therapy
- Some outpatient speech therapy
- Comprehensive outpatient rehabilitation facility services
- Rural health clinic services
- Institutional and home dialysis services, supplies and equipment
- Ambulatory surgical center services
- Antigens and blood clotting factors
- Qualified pyschologist services
- Therapeutic shoes for patients with severe diabetic foot disease
- Influenza, Pneumococcal, and Hepatitis B vaccine
- Some mammography screening
- Some pap smear screening, breast exams, and pelvic exams
- Some other preventive services including colorectal cancer screening,Diabetes training tests, bone mass measurements, and prostate cancer screening.
Medicare Part B is fairly comprehensive but far from complete. There are certain items and services which are excluded from coverage. Excluded services include:
- Services which are not reasonable or necessary
- Custodial care
- Personal comfort items and services
- Care which does not meaningfully contribute to the treatment of illness injury, or a malformed body member
- Prescription drugs which do not require administration by a physician
- Routine physical checkups
- Eyeglasses or contact lenses in most cases (see update below)
- Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses
- Hearing aids and examinations for hearing aids
- Immunizations except for influenza, pneumococcal and hepatitis B vaccine
- Cosmetic surgery
- Most dental services (but see update below, which contains a brief and hearing decision pertinent to coverage of medical-related dental services)
- Routine foot care (see update below).
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