1. What Does Medicare Cover under Part B?
What does Medicare 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.[1]
Medicare Part B covers medically necessary’ medical care such as:[2]
- 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.[3]
- 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.[4]
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:[5]
- 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). [6]
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.[8]
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.[9]
During Medicare’s General Enrollment Period (January 1–March 31), you can enroll in Part B, and your coverage will start July 1. [10]
5. How much does Medicare part B cost out-of-pocket?
To ensure that you pay the lowest possible premium for Medicare Part B coverage, it is advisable to secure 40 work credits over your life time. The amount of earnings it takes to earn a credit may change each year. In 2022, you earn one Social Security or Medicare credit for every $1,510 in covered earnings each year. You must earn $6,040 to get the maximum four credits for the year.
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 two 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.[11]
| 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. [12]
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:[13]
- Most doctor services (including most doctor services while you’re a hospital inpatient)
- Outpatient therapy
- Durable Medical Equipment (DME)
7. Medicare part B special enrollment and how and the open enrollment period.
There are certain situations when you can sign up for Medicare coverage under 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 special enrollment periods, or 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[14]
8. Does Medicare part B cover dental services/treatment?
Medicare does not cover dental services
No. [15]
9. Is it possible to get Medicare part B without paying a premium?
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.[16]
10. Reinstating Medicare coverage under part B if disenrolled
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. [17]
11. Your rights as a Medicare Insured
Medicare insureds have several rights, including:
- Receive care at any doctor or specialist, or Medicare-certified hospital, that participates in Medicare.
- Receive 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).[19]
Related Topics
Citations and Sources for Medicare Coverage Information and Policies
[1] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/about-us/how-is-medicare-funded
[2] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/what-part-b-covers
[3] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/what-part-a-covers
[4] 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
[5] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/whats-not-covered-by-part-a-part-b
[6] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/what-part-a-covers
[7] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/your-medicare-costs/costs-for-medicare-advantage-plans
[8] 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
[9] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/blog/medicare-part-b-enrollment-sign-up-now
[10] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/blog/medicare-part-b-enrollment-sign-up-now
[11] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/your-medicare-costs/part-b-costs
[12] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/your-medicare-costs/pay-part-a-part-b-premiums
[13] U.S. Government information website, Medicare.gov; Part B Costs – See https://www.medicare.gov/your-medicare-costs/part-b-costs
[14] 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
[15] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/what-medicare-covers/whats-not-covered-by-part-a-part-b
[16] 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
[17] U.S. HHS Centers for Medicare and Medicaid Services https://www.cms.gov/outreach-and-education/outreach/partnerships/downloads/11338-p.pdf
[18] U.S. Government information website, Medicare.gov. See https://www.medicare.gov/claims-appeals/your-medicare-rights/your-rights-in-original-medicare
[19] 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
