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Medicare Rx / Doctor Form

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What is Medicare Part B?

Medicare Part B is the category of Medicare Medical insurance coverage that includes various outpatient medical services, doctor services, and other home health services.  Part B is a voluntary program and Medicare-eligible individuals must enroll to receive the program's benefits.  To be eligible for Medicare Part B, one must be a U.S. Citizen over the age of 65 (or younger with a qualifying disability).  Most beneficiaries are automatically enrolled in Part B and will receive their Medicare card in the mail three months before their 65th birthday.  Those who are not automatically enrolled must fill out an application for Part B coverage.  If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty (see details below).

What does Part B cost?

You pay a premium each month for Medicare Part B (Medical Insurance).  Most people will pay the standard premium amount of $135.50 per month and elect to have it automatically deducted from their Social Security check; however, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA).  IRMAA is an extra charge added to your premium.

The amount you pay can change each year depending on your income.  If you have to pay a higher amount for your Part B premium and you disagree with the increased premium (for example, if your income goes down), you can contact Social Security.

2019 Part B annual deductible and copayments:

    - $185 - annual Part B Deductible

    - $0 copay for Medicare-approved clinical laboratory service

    - $0 copay for home health care services

    - 20% copay of the Medicare-approved amount for durable medical equipment, most doctor services, and                outpatient therapy outpatient hospital services

Part B Late Enrollment Penalty

If you don't sign up for Part B when you're first eligible or if you drop Part B and then get it later, you may have to pay a late enrollment penalty for as long as you have Medicare.  Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it.

Usually, you don't pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a Special Enrollment Period.

If you have limited income and resources, your state may help you pay for Part A and/or Part B.

What does Part B cover?

Medicare Part B helps cover doctor's services and outpatient care.  It also covers some other medical services that Part A doesn't cover, such as physical and occupational therapists, and some home health care.  Part B helps pay for these covered services and supplies when they are medically necessary.

Part B Covers 2 Types of Services:

     - Medically necessary services:  Services or supplies that are needed to diagnose or treat your medical

        condition and that meet accepted standards of medical practice.

     - Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when

        treatment is most likely to work best.  You pay nothing for most preventive services if you get the    

        services from a health care provider who accepts assignment.

Typical services covered by Part B:

     - Yearly wellness exams

     - Diagnostic tests / lab work / screenings

     - Doctor services

     - Ambulance services

     - Nursing services

     - Chemotherapy

     - Certain diabetic supplies

     - Flu and pneumonia vaccinations

     - Durable medical equipment (e.g. wheelchairs, walkers, etc.)

     - Some mammography and pap smear screening

Part B does NOT cover:

     - Prescription drugs (that are not administered to you by a physician)

     - Routine physical check-ups aside from yearly wellness exams

     - Alternative care such as acupuncture

     - Vaccinations or immunizations other than for the flu and pneumonia 

     - Eye glasses

     - Hearing aids and exams for fitting them

     - Most dental care

     - Dentures

     - Cosmetic surgery

Medicare Part B covered services are reimbursed at 80% of the "reasonable charge" for the service.  The person receiving the service is responsible for paying the remaining 20%.  However, this "reasonable charge" is determined by Medicare and may not adequately reflect the costs you pay to your physician. When a doctor agrees to accept the Medicare set "reasonable charge" as full payment, he or she is said to accept "assignment."  When a doctor does not accept "assignment", the patient is responsible for paying the outstanding balance minus the Medicare approved amount.  However, federal law sets a limit as to the maximum amount a doctor may bill for a service.  The maximum amount to be billed for a Medicare Part B covered service is 15% of the Medicare approved amount.  If the doctor bills above this cap, he or she violates the federal law.