Medicare Part B Overview

1.    What is Medicare Part B is and what does it cover?

Medicare is health insurance for:

  • People 65 or older
  • Under 65 with certain disabilities
  • People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)

Medicare Part B is federal medical insurance that is funded by a Medicare payroll tax withheld from income taxpayers.  In 2017, Medicare-covered over 58 million people. Total expenditures in 2017 were $705.9 billion. This money comes from the Medicare Trust Funds.  The Supplemental Medical Insurance Fund (SMI) Trust fund pays for Part B benefits. 

Medicare Part B covers’ medically necessary’ medical care such as:

  • Medical care provided in non-overnight stays at locations like a physician’s office, a surgery center, or an emergency room that does not result in an overnight inpatient stay in a hospital.
  • Clinical research
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health for both inpatients and outpatients and partial hospitalization
  • Limited outpatient prescription drugs

Medicare National Coverage Determinations (NCDs) and Medicare Local Coverage Determinations (LCDs) are published policies administered by Medicare Administrative Contractors (MACs) in different regions or jurisdictions.

2.    What does Medicare part B not cover? How do you get coverage elsewhere for these non-covered events/items?

No original Medicare coverage is provided for these medical services:

  • Long-Term Care (also called custodial care)
  • Most dental care
  • Eye exams related to prescribing glasses
  • Dentures
  • Cosmetic surgery
  • Acupuncture
  • Hearing aids and exams for fitting them
  • Routine foot care

In general, Medicare Part B only covers outpatient medical care (with exceptions for some inpatient mental health care).

To receive coverage for what Medicare Part B does not cover, a Medicare-eligible patient may receive coverage under Medicare Part A or purchase extra benefits and coverage under a Medigap Policy, which may be purchased separately, or a Medicare Part C (“Medicare Advantage”) plan that may have no premium or depending on what the plan offers,  payment of a separate premium.

3.    Who is eligible for Medicare part B? What do you need to do to qualify?

Generally, Medicare is available for people aged 65 or older, younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). Medicare has two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least ten years. You can get Part A at age 65 without having to pay premiums if:

  • You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
  • You are eligible to receive Social Security or Railroad benefits, but you have not yet filed for them.
  • You or your spouse had Medicare-covered government employment.

To find out if you are eligible and your expected premium, go to the Medicare.gov eligibility tool.

If you (or your spouse) did not pay Medicare taxes while you worked, and you are age 65 or older and a citizen or permanent resident of the United States, you may be able to buy Part A. If you are under age 65, you can get Part A without having to pay premiums if:

  • You have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months. (Note: If you have Lou Gehrig’s disease, your Medicare benefits begin the first month you get disability benefits.)
  • You are a kidney dialysis or kidney transplant patient.

While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every three months.

4.    How do you sign up for and get enrolled in Medicare part B? How long does it take to get Medicare part B coverage after applying?

There are three ways you can sign up:

Fill out a short form and send it to your local Social Security office.

Call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

Contact your local Social Security office.

During Medicare’s General Enrollment Period (January 1–March 31), you can enroll in Part B, and your coverage will start July 1.

5.    How much does Medicare part B cost out-of-pocket?

 

The standard Part B premium amount in 2021 is $148.50. Most people pay the standard Part B premium amount. If your modified adjusted gross income, as reported on your IRS tax return from 2 years ago, is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.

If your yearly income in 2019 (for what you pay in 2021) was You pay each month (in 2021)
File individual tax return File joint tax return File married & separate tax return
$88,000 or less $176,000 or less $88,000 or less $148.50
above $88,000 up to $111,000 above $176,000 up to $222,000 Not applicable $207.90
above $111,000 up to $138,000 above $222,000 up to $276,000 Not applicable $297.00
above $138,000 up to $165,000 above $276,000 up to $330,000 Not applicable $386.10
above $165,000 and less than $500,000 above $330,000 and less than $750,000 above $88,000 and less than $412,000 $475.20
$500,000 or above $750,000 and above $412,000 and above $504.90

 

If you get Social Security or Railroad Retirement Board (RRB) benefits, your Part B (Medical Insurance) premium will get deducted automatically from your benefit payment.  If you don’t get benefits, you’ll get a bill to pay your premiums.

6.    Please explain the Medicare part B deductible and how it works.

If you have medical claims you pay $203 for your Part B deductible. After you meet the deductible for the year, you typically pay 20% of the Medicare allowed amount for:

  • Most doctor services (including most doctor services while you’re a hospital inpatient)
  • Outpatient therapy
  • Durable Medical Equipment (DME)

7.    Please explain the Medicare part B special enrollment period, and how and when it’s possible to sign up outside of the open enrollment period.

There are certain situations when you can sign up for Part B (and Premium-Part A) during a Special Enrollment Period without paying a late enrollment penalty. A Special Enrollment Period (SEP) is only available for a limited time. If you don’t sign up during your Special Enrollment Period, you’ll have to wait for the next General Enrollment Period, and you might have to pay a monthly late enrollment penalty.

You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage. Rules about when you can make changes and the type of changes you can make are different for each SEP.

These SEPs include:

You change where you live

You lose your current coverage

You have a chance to get other coverage

Your plan changes its contract with Medicare

Other special situations (such as Medicaid and Medicare eligibility or dropped a Medigap policy

8.    Does Medicare part B cover dental services/treatment?

 

No.

9.    Is it possible to get Medicare part B for free?

While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every three months.

10. How can I get reinstated for Medicare part B if I lost my coverage?

A plan can choose to disenroll a member who fails to pay plan premiums after proper notice and the plan’s grace period. Disenrollment for failure to pay plan premiums is optional for each plan, so it’s important for the member to know the rules for that plan. The plan will tell members the policy and length of the grace period (which must be at least two months) in the “Annual Notice of Change” and “Evidence of Coverage” sent each fall. The plan must apply the policy consistently to all members of the plan.

If a Medicare plan disenrolls a member for failing to pay drug premiums and the member wants to re-enroll in the plan, the Medicare plan may require them to pay any outstanding premiums owed before accepting the enrollment request. Also, the member must re-enroll during a valid enrollment period since payment of past due to drug premiums after disenrollment doesn’t create an opportunity for reinstatement into the plan. Re-enrollments after losing coverage for nonpayment of drug premiums are never retroactive.

11.  Your rights as a Medicare Insured

Medical patients insured by Medicare have several important rights, including:

  • See any doctor or specialist (including women’s health specialists), or go to any Medicare-certified hospital, that participates in Medicare.
  • Get certain information, notices, and appeal rights. These help you resolve issues when Medicare may not or doesn’t pay for health care.
  • Request an appeal of health coverage or payment decisions.
  • Buy a Medicare Supplement Insurance (Medigap Policy).
  • The expectation is that Medicare and Medicare healthcare providers will maintain the privacy of an insured’s Protected Health Information (PHI) and electronic Protected Health Information (ePHI).

Related Topics

Medicare Fraud Expert Witness

Citations and Sources

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/about-us/how-is-medicare-funded

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/what-part-b-covers

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/what-part-a-covers

Centers for Medicare and Medicaid Services (CMS).  Local coverage determinations (LCDS) are defined in Section 1869(f)(2)(B) of the Social Security Act (the Act). This section states: “For purposes of this section, the term ‘local coverage determination’ means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).”   See https://www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/whats-not-covered-by-part-a-part-b

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/what-part-a-covers

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/your-medicare-costs/costs-for-medicare-advantage-plans

U.S. Department of Health and Human Services (HHS).  See https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/blog/medicare-part-b-enrollment-sign-up-now

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/blog/medicare-part-b-enrollment-sign-up-now

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/your-medicare-costs/part-b-costs

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/your-medicare-costs/pay-part-a-part-b-premiums

U.S. Government information website, Medicare.gov; Part B Costs – See https://www.medicare.gov/your-medicare-costs/part-b-costs

U.S. Government information website, Medicare.gov; – See https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/special-circumstances-special-enrollment-periods

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/whats-not-covered-by-part-a-part-b

U.S. Department of Health and Human Services (HHS).  See https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html

U.S. HHS Centers for Medicare and Medicaid Services https://www.cms.gov/outreach-and-education/outreach/partnerships/downloads/11338-p.pdf

U.S. Government information website, Medicare.gov. See https://www.medicare.gov/claims-appeals/your-medicare-rights/your-rights-in-original-medicare

Protected Health Information. The Privacy Rule protects all “individually identifiable health information” held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information “protected health information (PHI).  See 45 C.F.R. § 160.103.  https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html

 

 

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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