Medicare Part B Coverage

Part B of Medicare helps pay for certain outpatient services that are needed outside of the hospital. Generally, those who are eligible for Part A benefits will be enrolled in Part B unless they elect not to take the coverage. Medicare Part B has a calendar year deductible, unlike Part A which has a per occurrence deductible. After the patient has paid the deductible, Part B will cover 80% of the approved charges for doctor’s services and other services that are covered under Part B (medical insurance). Most often the patient assigns his or her right to collect Medicare benefits to his or her doctors, and the doctors submit their assigned claims directly to Medicare. The patients are then billed by the doctor for the 20% coinsurance amount.

Medicare Part B Services

Outpatient Services Covered under Part B

  • Medical & surgical services including anesthesia.
  • Doctors’ services provided on an inpatient or outpatient basis.
    • This includes the cost of house calls, office visits, and doctors’ services in a hospital or other institution.
    • Included in this category are the fees of physicians, surgeons, anesthesiologists, radiologists, pathologists, psychiatrists, and osteopaths.
    • Diagnostic tests and procedures that are part of the patient’s treatment.
    • Pathology and radiology services on an inpatient or outpatient basis.
    • Outpatient physical, occupational and speech therapy.
      • Outpatient physical therapy and speech pathology services received as part of a patient’s treatment in a doctor’s office or as an outpatient of a participating hospital, skilled nursing facility, or home health agency if the services are furnished under a written plan established by a physician or physical therapist.
      • Payment for services of independent physical and occupational therapists is limited to a maximum dollar amount in any one year.
      • X-rays. Radiation therapy with X-ray, radium, or radioactive isotopes.
      • Services of doctor’s office nurse.
        • Services from certain specially qualified practitioners who are not physicians but are approved for Medicare.
        • These specially qualified practitioners include certified nurse anesthetists, clinical social workers, physician assistants, and nurse practitioner and clinical nurse specialists in collaboration with a physician.
        • Ambulance service if required.
        • Drugs that cannot be self-administered.
          • Services and supplies relating to a physician’s services and hospital services rendered to outpatients.
          • Included in this category are drugs which cannot be selfadministered.
          • Treatment of mental illness (copayment is 50%).
            • The cost of psychiatric treatment outside a hospital for mental, psychoneurotic, or personality disorders.
            • There is a 50% coinsurance on these services.
            • However, if the psychiatric treatment is provided on a hospital outpatient basis and the patient would have had to have been hospitalized had treatment not been provided on a hospital outpatient basis; then, the usual 20% coinsurance will apply.
            • Transfusions of blood and blood components. Included in this category is the cost of blood clotting factors and supplies necessary for the self administration of the clotting factor.
            • Lung transplants and heart-lung transplants. Physician services and other non hospital services related to the transplant are covered under this Part as well as pre-and post-transplant care by the professionals.
            • Certain immuno-suppressive drugs given in conjunction with organ transplants.
            • Medical equipment. Surgical dressings, casts, splints, and other devices for fixing fractures and dislocations; rental and purchase of durable medical equipment, such as iron lungs, oxygen tents, hospital beds, and wheelchairs for use in the patient’s home; prosthetic devices, such as artificial heart valves or synthetic arteries designed to replace part or all of an internal organ; braces, artificial limbs, and artificial eyes..
            • Home health care visits.
              • Also covered under Part B are home health care visits that have been authorized by a physician.
              • There is no limit to the number of home health care services covered under Part B each year.
              • These home health care services are covered under Part A unless the patient only has Part B coverage.
              • One pair of eyeglasses following cataract surgery.
              • Dental work for jaw or facial bone surgery whether required because of accident or disease. Moreover, hospital stays warranted by the severity of the uncovered dental procedure and services provided by dentists which would be covered under current law when provided by a physician are also covered.
              • Certified nurse-midwife services.
              • Emergency room services and same day surgery.
              • Mammography. Screening mammography, which is defined as a radiologic procedure provided to a woman for the early detection of breast cancer, including a physician’s interpretation of the result of the procedure.
              • Pap smears for the early detection of cervical cancer.
              • Services of clinical psychologists are covered if they would otherwise be covered if furnished by a physician.
              • Services by a licensed chiropractor for manual manipulation of the spine to correct a defect that was shown in an X-ray.
              • Fees of podiatrists. However, routine foot care is not covered.
              • The costs to diagnose and treat eye and ear ailments.
              • Plastic surgery for repair of an accidental injury, an impaired limb or a malformed part of the body.
              • Outpatient rehabilitation facility service performed by a doctor or other qualified professional in a qualified facility.
              • Oral cancer drugs in certain cases.
              • The cost of injectable drugs approved for the treatment of bone fractures related to postmenopausal osteoporosis. The patient’s attending physician must certify that the patient is unable to learn the skills needed to self-administer and the patient must meet the requirements for Medicare coverage for home health services.

Services Not Requiring a Deductible or Copayment

  • Cost of a second opinion for surgery that is required by
  • Medicare.
  • Home health services.
  • Influenza and hepatitis B vaccinations.
  • Outpatient clinical diagnostic tests by doctors who accept assignments or by a Medicare approved facility.

Services Not Covered Under Part B

  • Routine physical exams and related tests.
  • Routine dental care and foot care.
  • Eyeglass or hearing aid exams.
  • Acupuncture.
  • Services required as a result of war.
  • Immunizations except for pneumococcal pneumonia vaccinations and hepatitis B for persons at risk.
  • Cosmetic surgery unless required due to accident or to improve a malfunctioning part of the body.
  • Most prescription drugs.

Medicare Part B Benefits

Medicare (Part B): Hospital Insurance Services Benefit

Medical Expense

Physician’s services, inpatient and outpatient medical, and surgical services, and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. Medicare pays for medical services in or out of the hospital.

Clinical Laboratory Services Blood tests, biopsies, urinalysis, etc.

Home Health Care

Medically necessary skilled care, home health aide services, medical supplies, Part-time or intermittent nursing care and other services for as long as the criteria for benefits are met.

Outpatient Hospital Treatment Reasonable and necessary services for the diagnosis or treatment of an illness or injury. Unlimited if medically necessary.

Covered Services Per Calendar Year

Medicare Pays You Pay

  • 80% of approved amount (after $100 deductible.)
  • $100 deductible, *plus 20% of approved amount and any charge above approved amount.
  • 100% of approved amount Nothing for services.
  • 100% of approved amount:
  • 80% of approved amount for durable medical equipment.
  • Nothing for services: 20% of approved amount for durable medical equipment.
  • 80% of approved amount (after $100 deductible).
  • Subject to deductible plus 20% of approved amount.
  • 80% of approved amount (after $100 deductible and starting with 4th pint).
  • First 3 pints plus 20% of approved amount for additional pints (after $100 deductible.)
  • Medicare Benefits Charts
  • These charts describe Medicare benefits only. The ‘You Pay’ column itemizes expenses you are responsible for and must pay out of your own pocket or through the purchase of some type of private insurance.