What Is Medicare Part B?

Medicare Part B is one of the four parts of the government health insurance ‘Medicare’. Keep reading this detailed guide to learn more.

Medicare is a federally supported health insurance program for people who are 65 years old or more and other specific groups. It consists of various parts, one of which is Part B. Medicare Part B assists in covering medical services like doctors’ appointments, outpatient care, and other medical services that Part A does not cover. Part B is not compulsory to have. Part B helps pay for covered medical services and items when they are medically necessary. Part B also provides coverage for some preventive services like exams, lab tests, and screening shots to help avoid, diagnose, or manage a medical problem. Medicare Part B is the part of Medicare that provides medical insurance. Keep on reading to learn more regarding what is Medicare Part B, what it covers, how much it costs, and when to enroll.

What is Medicare Part B and do I need it?

This Medicare part covers doctor visits, lab tests, diagnostic screenings, clinical equipment, ambulance transportation and other outpatient services. Unlike Part A, Part B involves more expenses, and you might want to delay signing up for it in case you are still working and have insurance through your employer or are covered by your spouse’s health plan. However, in the event that you do not have other insurance and do not sign up for Part B when you initially enroll in Medicare, you will probably need to pay a higher monthly premium for as long as you are in the program.

In the event that you have Part B, you pay a Part B premium every month. The vast majority will pay the standard premium amount. The federal government sets the Part B monthly premium, which is $148.50 for 2021. It very well might be higher if your income is more than $88,000. You will likewise be subject to a yearly deductible, set at $203 for 2021. Furthermore, you will need to pay 20% of the bills for doctor visits and other outpatient services. In case you are getting Social Security, the monthly premium will be deducted from your monthly benefit. This will be covered in more detail later on.

Social Security will get in touch with certain individuals who need to pay more depending on their income. In the event that you do not sign up for Part B when you are first eligible, you might need to suffer a late enrollment consequence. For more information about enrolling in Medicare, look at your copy of the “Medicare and You” handbook, call Social Security at 1-800-772-1213, or visit your local Social Security office. In the event that you get benefits from the Railroad Retirement Board (RRB), call your neighborhood RRB office or 1-800-808-0772.

Types of Medicare providers

Use the Medicare provider search tool to find quality data, services offered, and other information. You can find and compare nursing homes, hospitals, doctors, and other health care providers in your region that accept or provide Medicare. You can get information regarding:

  • Contact information for local inpatient rehabilitation centers
  • Dialysis facilities and hospitals near you
  • Estimate of doctors’ costs in your area
  • Quality ratings for local nursing homes and home health agencies

The kind of providers you will get information for are as follows:

Nursing homes

Get information in detail about every Medicare-certified nursing home in the country. A nursing home is a place where those who cannot be cared for at home and need 24-hours of nursing care, are looked after. You can search for nursing homes by location and compare the quality of care they give.

Hospitals

Look for and compare hospitals that provide services like medical, surgical, and psychiatric care. Use the “Hospital type” filter to come across special facilities, like acute care, critical access, children’s hospitals, and more.

Doctors & clinicians

You can search for a doctor or clinician that accepts or provides Medicare near you, or compare doctors who are qualified to practice in many specialties.

Home health services

Home health care includes a wide range of health care services that you can get in your home at a far lesser cost than a hospital or skilled nursing facility. Compare home health agencies through the patient survey star ratings or the quality of patient care star rating.

Hospice care

Hospice care facilities and agencies often provide services where you live, whether you are at home, an assisted living facility, or a nursing home. You can look for hospices that serve in your region and compare the quality of care they give.

Inpatient rehabilitation facilities

Many patients with conditions like stroke or brain injury, who need an intensive medical rehabilitation program, are sent to an inpatient rehabilitation facility. Look for and compare inpatient rehabilitation facilities based on infection rates and more.

Long-term care hospitals

Many people who need to be in intensive care for a longer time are often sent to a long-term care hospital to continue that care. You can look for and compare long-term care hospitals based on essential indicators of quality, like how often patients get infections or pressure ulcers.

Dialysis facilities

You can also get information on more than 7,000 facilities all over the country. Compare dialysis centers and make a decision based on the quality of patient care they give. You can also compare their patient experience survey results.

Medical supplies & equipment

Search for suppliers, cost estimates, and availability information for medically necessary durable medical equipment (DME) that Medicare covers.

Medicare Part B eligibility

Medicare Part B is a health insurance option that is available for people in the United States as soon as they reach the age of 65. Nevertheless, there are certain situations under which you may be eligible to enroll in Medicare Part B before the age of 65.

Anyone who is qualified for premium-free Medicare Part A is qualified for Medicare Part B by enrolling and paying a monthly premium. If you are not qualified for premium-free Medicare Part A, you can be eligible for Medicare Part B by meeting the following conditions:

  • You must be a U.S. citizen, or a permanent resident lawfully residing in the U.S for at least five continuous years.
  • You must be 65 years or older.

You can also be eligible for automatic Medicare Part B enrollment through disability. If you are less than 65 years old, and getting Social Security or Railroad Retirement Board (RRB) disability benefits, you will be enrolled automatically in Medicare Part A and Part B after 2 years of getting disability benefits. You may also be qualified for Medicare Part B enrollment if you have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (also known as ALS, or Lou Gehrig’s disease).

Let us look at these eligibility requirements in slightly more detail.

You are 65 years old

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You are automatically eligible for Medicare Part B once you turn 65 years old. Keep in mind that you will need to wait to use your benefits until your 65th birthday. You can enroll:

  • 3 months before your 65th birthday
  • including your 65th birthday month
  • 3 months after your 65th birthday

You have a disability

If you have a disability and are getting Social Security or Railroad Retirement Board disability benefits, you are eligible to enroll in Medicare Part B, regardless of your age. As per the Social Security Administration, qualifying disabilities may include:

  • cardiovascular and blood disorders
  • digestive system disorders
  • mental disorders
  • neurological disorders
  • sensory disorders

You have ESRD or ALS

If you have been diagnosed with end stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS), you are qualified to sign up for Medicare Part B, even if you are not yet 65 years old.

Medicare Part B enrollment

Who is automatically enrolled?

Groups that are automatically enrolled in original Medicare are:

  • people who are turning age 65 years old and already getting retirement benefits from the Social Security Administration (SSA) or the Railroad Retirement Board (RRB)
  • people less than 65 years old who have a disability and are receiving disability benefits from the SSA or RRB for 24 months
  • people with amyotrophic lateral sclerosis (ALS) who are getting disability benefits

It is essential to keep in mind that even though you will be automatically enrolled, Part B is not compulsory. You can choose to delay Part B if you want. One situation where this may happen is if you are already covered by another plan through your employer or a spouse.

Who must sign up?

Note that not everyone who is qualified for original Medicare will be automatically enrolled. However, some will need to sign up through the SSA office:

  • People who are turning 65 years old and are not yet getting retirement benefits from the SSA or RRB can sign up starting 3 months before they turn age 65.
  • People with ESRD can sign up at any time — when your coverage begins may differ.

You can sign up for Medicare Part B during the following periods:

  • Initial Enrollment Period (IEP): This is when you are first eligible to sign up for Medicare, either by turning 65 or through disability. On the off chance that you qualify due to your age, your Initial Enrollment Period begins three months before you turn 65 and goes on for seven months. In the event that you fit the bill for Medicare due to disability, your Initial Enrollment Period begins three months before your 25th month of disability benefits from Social Security or the Railroad Retirement Board and keeps going seven months.
  • Open enrollment period (OEP): This period starts from October 15 and ends on December 7. During this time, you can change from Original Medicare (parts A and B) to Part C (Medicare Advantage), or you can go back from Original Medicare to Part C. You can also switch Part C plans or add, remove, or change a Part D plan.
  • General Enrollment Period (GEP): On the off chance that you missed your Initial Enrollment Period, you can likewise sign up for Medicare Part B during this period, which occurs from January 1 to March 31 yearly. If you sign up for Medicare Part B during the General Enrollment Period, your inclusion will come full circle on July 1 of the year that you joined. However, if you did not select Medicare Part B when you were first eligible, you might need to suffer a late-enrollment penalty, and your Medicare Part B premium might be 10% higher for every 12-month period that you could have had Medicare Part B, but chose not to get it.
  • Special Enrollment Period (SEP): You might choose to delay your Medicare Part B enrollment if you or your spouse are working and have group health insurance dependent on your current business. At the point when you or your spouse resigns and you lose your group health inclusion, you will be given a Special Enrollment Period to join up with Medicare Part B. The Special Enrollment Period is the eight-month time frame following the month when the employer coverage ends or you quit working (whichever happens first). You can enroll any time you and your spouse remain covered by the group health plan or during the Special Enrollment Period.

You can enroll in Medicare Part B through Social Security in the following ways:

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  • Call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778. Social Security representatives are available Monday through Friday, from 7AM to 7PM.
  • In-person. You can do this at a local Social Security office.
  • Online at SSA.gov. If you are not yet ready to apply for retirement benefits, you can apply for Medicare only.
  • Through the Railroad Retirement Board. If you worked at a railroad, you can apply for Medicare through the Railroad Retirement Board, not Social Security. Contact the Railroad Retirement Board to enroll at 1-877-772-5772 (TTY users, call 1-312-751-4701); Monday through Friday, from 9AM to 3:30PM.

Can I delay enrolling in Medicare Part B?

A few individuals might get Medicare Part A “premium-free,” however the vast majority need to pay a monthly premium for Medicare Part B. Since Medicare Part B comes with a monthly premium, some people might decide not to enroll during their initial enrollment period in case they are still covered under an employer group plan (either their own or through their spouse’s employer).

In case you are as yet working, you should check with your health benefits administrator to understand how your insurance would function with Medicare. In the event that you postpone enrollment in Medicare Part B since you still have current employer health inclusion, you can join later during a Special Enrollment Period without paying a late penalty. You can enroll in Medicare Part B at any time that you are still covered by a group plan dependent on current employment. After your employer health inclusion closes or your work ends (whichever comes first), you have an eight-month special enrollment period to enroll in Part B without a late penalty.

Remember that retiree coverage and COBRA are not viewed as health inclusion dependent on current business and would not qualify you for a special enrollment period. On the off chance that you have COBRA after your employer coverage ends, you ought not wait until your COBRA coverage finishes to enroll in Medicare Part B. Your eight-month Part B special enrollment period begins after your present employment or group plan closes (whichever comes first). This is regardless of whether or not you get COBRA.

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What does Medicare Part B cover?

Part B covers 2 types of services:

  • Medically necessary services: Services, products or supplies that are required to diagnose or treat your medical condition. The services need to meet accepted standards of medical practice.
  • Preventive services: Health care to prevent illness (like the flu) or diagnose it at an early stage, when treatment is most likely to work best.

You do not have to pay anything for most preventive services if you get the services from a health care provider who accepts assignments.

Medicare coverage is based on 3 main factors:

  • Federal and state laws.
  • Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
  • National coverage decisions made by Medicare about whether something is covered.

There are two ways to find out if Medicare covers what you need:

  • Get in touch with your doctor or other health care provider and ask them why you need certain services or supplies. Make sure to question if Medicare will cover them. You may need something that is usually covered but your provider thinks that Medicare will not cover it in your situation. If so, you will have to read and sign a notice. The notice will say that you may have to pay for the item, service, or supply.
  • Make sure to find out if Medicare covers your item, service, or supply.

Look at your Medicare card to find out if you have Part B. The basic medically-necessary services covered include:

  • Abdominal Aortic Aneurysm Screening
  • Ambulance Services
  • Blood
  • Bone Mass Measurement (Bone Density)
  • Cancer screenings like those for breast, colorectal, and prostate cancers
  • Cardiac Rehabilitation
  • Cardiovascular Screenings
  • Chemotherapy services
  • Chiropractic Services (limited)
  • Clinical Laboratory Services
  • Clinical Research Studies
  • Colorectal Cancer Screenings
  • Defibrillator (Implantable Automatic)
  • Diabetes Screenings
  • Diabetes Self-Management Training
  • Diabetes Supplies
  • Doctor Services
  • Durable Medical Equipment (like walkers)
  • EKG Screening
  • Emergency Department Services
  • Eyeglasses (limited)
  • Federally-Qualified Health Center Services
  • Flu shots
  • Foot Exams and Treatment (Diabetes-related)
  • Glaucoma Tests
  • Hearing and Balance Exams
  • Hepatitis B Shots
  • HIV Screening
  • Home Health Services
  • Kidney Dialysis Services and Supplies
  • Kidney Disease Education Services
  • Mammograms (screening)
  • Medical Nutrition Therapy Services
  • Mental Health Care (outpatient)
  • Non-doctor Services
  • Occupational Therapy
  • Outpatient Medical and Surgical Services and Supplies
  • Pap Tests and Pelvic Exams (includes clinical breast exam)
  • Physical Exams
  • Physical Therapy
  • Pneumococcal Shot
  • Prescription Drugs (limited)
  • Prostate Cancer Screenings
  • Prosthetic/Orthotic Items
  • Pulmonary Rehabilitation
  • Rural Health Clinic Services
  • Screenings for hepatitis B, hepatitis C, and HIV
  • Second Surgical Opinions
  • Sexually transmitted infection (STI) screening
  • Smoking Cessation (counseling to stop smoking)
  • Speech-Language Pathology Services
  • Surgical Dressing Services
  • Telehealth
  • Tests (other than lab tests)
  • Transplants and Immunosuppressive Drugs

What does Medicare Part B not cover?

There are certain services that are not covered by Part B. If you require these services, you will need to pay for them out of pocket. Some examples of these include:

  • alternative health services like acupuncture and massage
  • cosmetic surgery
  • dental care, including dentures
  • hearing aids
  • long-term care
  • most prescription drugs
  • most vision care, including eyeglasses or contact lenses
  • routine physical examinations

If you would like prescription drug coverage, you can buy a Medicare Part D plan. Part D plans are provided by private insurance organizations and include most prescription drugs. Moreover, Medicare Part C (Medicare Advantage) plans incorporate all services covered under original Medicare along with some additional services like dental, vision, and even fitness programs. If you know you will need these services frequently, consider a Part C plan.

Do you have to pay for Medicare Part B?

Medicare Part B premiums may vary from year to year, and the sum can change based on your circumstances. For many individuals, the premium is automatically deducted from their Social Security benefits. The standard monthly Part B premium is $148.50 in 2021. If you earn over a certain amount, your premium could be more than the standard premium, since there are different premiums for different income levels.

If you are getting Social Security, Railroad Retirement Board, or federal retirement benefits, your Part B premium will directly be deducted from your monthly benefit. If not, you will be sent a bill every three months.

Let us look below at Medicare Part B monthly premium sums, based on peoples’ reported income from two years ago (2019). These amounts may change every year. A late enrollment penalty may be applied if you did not enroll in Medicare Part B when you were first eligible. Your monthly premium may be 10% more for each 12-month period that you were qualified, but did not enroll in Part B.

Medicare Part B monthly premium in 2021:

  • You pay $148.50 if your yearly income is $88,000 or less, and you filed an individual tax return; If you filed a joint tax return, you pay $176,000 or less
  • You pay $207.90 if your yearly income is $88,001 – $111,000, and you filed an individual tax return; If you filed a joint tax return, you pay $176,001 – $222,000
  • You pay $297 if your yearly income is $111,001 – $138,000, and you filed an individual tax return; If you filed a joint tax return, you pay $222,001 – $276,000
  • You pay $386.10 if your yearly income is $138,001 – $165,000, and you filed an individual tax return; If you filed a joint tax return, you pay $276,001 – $330,000
  • You pay $475.20 if your yearly income is $165,001 to less than $500,000, and you filed an individual tax return; If you filed a joint tax return, you pay $330,001 to less than $750,000
  • You pay $504.90 if your yearly income is $500,000 or more, and you filed an individual tax return; If you filed a joint tax return, you pay $750,000 or more
  • You pay $148.50 if you are married but you file a separate tax return from your spouse and your yearly income is $88,000 or less
  • You pay $475.20 if you are married but you file a separate tax return from your spouse and your yearly income is $88,001 to less than $412,000
  • You pay $504.90 if you are married but you file a separate tax return from your spouse and your yearly income is $412,000 or more

Medicare Part B costs

Now let us take a look at each of the expenses associated with Part B in 2021.

Monthly premium

Your monthly premium is the amount that you pay every month for Part B inclusion. For 2021, the standard Part B monthly premium is $148.50. Individuals with higher yearly incomes might need to pay higher monthly premiums. Your yearly income is determined dependent on your tax return from two years prior. So for 2021, this would be your 2019 expense form. There is likewise a late enrollment penalty that can influence your Part B monthly premium. You will pay this on the off chance that you did not sign up for Part B when you were first eligible. At the point when you need to pay the late enrollment penalty, your monthly premium can increase up to 10 percent of the standard premium for every 12-month period that you were eligible for Part B but did not sign up. You will pay this as far as you are enrolled in Part B.

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Deductibles

A deductible is the amount you need to pay out-of-pocket before Part B begins covering services. For 2021, the deductible for Part B is $203.

Coinsurance

Coinsurance is the percentage of the expense of a service that you pay out of pocket after meeting your deductible. This is usually 20 percent for Part B.

Copays

A copay is a set sum that you pay for a service. Copays are not typically associated with Part B. However,there are some cases where you might be required to pay one. For example if you use hospital outpatient services.

Out-of-pocket maximums

An out-of-pocket maximum is a limit on the amount you will have to pay out of your own pocket for covered services during the year. Original Medicare does not have an out-of-pocket maximum.

Conclusion

Medicare Part B is the part of Medicare that covers medically vital outpatient services. It additionally covers some preventative services. It is part of the Original Medicare. Individuals who are 65 years old or more, have a disability, or ESRD are eligible for Part B. The expenses of part B include monthly premiums, a deductible, and coinsurance or copay. A few services are not covered by Part B and should be paid out-of-pocket. Many individuals are automatically enrolled in original Medicare. Some should join through the SSA. For these individuals, focusing on enrollment deadlines is important.

John Otero

John Otero

John Otero is an industry practitioner with more than 15 years of experience in the insurance industry. He has held various senior management roles both in the insurance companies and insurance brokers during this span of time. He began his insurance career in 2004 as an office assistant at an agency in her hometown of Duluth, MN. He got licensed as a producer while working at that agency and progressed to serve as an office manager. Working in the agency is how he fell in love with the industry. He saw firsthand the good that insurance consumers experienced by having the proper protection. John has diverse experience in corporate & consumer insurance services, across a range of vocations. His specialties include Major Corporate risk management and insurance programs, and Financial Lines He has been instrumental in making his firm as one of the leading organizations in the country in generating sustainable rapid growth of the company while maintaining service excellence to clients.

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