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Lesson 06: Medicare Part B

Medicare Part B

Medicare Part B helps pay for physicians` services, outpatient hospital care, ambulance services, prosthetic devices, medical equipment, and a number of other health services and supplies that are not covered by Medicare`s hospital insurance. Medicare Part B has certain out-of-pocket expenses, including a monthly premium, an annual deductible, and coinsurance. The monthly Part B premium is usually deducted from a beneficiary`s Social Security check. The Part B premium typically increases each year. 

An annual deductible must be met before Medicare Part B begins paying for services. Only Medicare approved charges apply toward the annual deductible. Medicare Part B usually pays 80% of the Medicare-approved charges. The patient must pay the remaining 20%, either out-of-pocket or through other insurance options. There are, however, a few exceptions

  • The patient pays a fixed co-payment for outpatient services.
  • Medicare pays only 50% of outpatient psychiatric services.
  • Medicare pays 100% of clinical lab services.
The following help to fill the gaps in Medicare Coverage:
  • Medicare Supplemental Insurance • Retiree or Union Insurance Coverage
  • Medicare Savings Programs: QMB, SLMB, QI1
  • Full Medicaid

Part B Payments and Covered Services

Medicare Part B payments are based upon an amount called the "approved charge." It may also be referred to as the "reasonable charge," "allowable charge," or "acceptable charge." Medicare maintains a fee schedule for doctors and suppliers that lists the approved charge for each service offered under Part B.

Some physicians and suppliers accept assignment and some do not. Those who accept assignment agree to accept the Medicare-approved amount as payment in full." Medicare Part B pays 80% of the approved amount, and the patient pays 20% of the approved some do not.

Part B pays for services performed by these doctors:

  • Doctors of Medicine (M.D.)
  • Doctors of Osteopathy (D.O.)

Part B pays for limited services from these practioners:

  • Chiropractors
  • Dentists
  • Optometrists
  • Podiatrists
Part B Covered Services:
  • Diagnostic tests and procedures that are part of the patient`s treatment.
  • Radiology and pathology services.
  • Medical and surgical services including anesthesia.
  • Transfusions of blood and blood components (beginning with the 4th pint).
  • Visit to physician for second opinion about recommended surgery.
  • Drugs that must be administered by a medical professional.
  • Immunosuppressive drugs for persons who have had organ transplants while already enrolled in Medicare.
  • Outpatient treatment of mental illness.
  • Payment for Durable Medical Equipment (DME) and Supplies

Durable Medical Equipment coverage conditions that must be met before Medicare Part B will pay:

  • Physician must order or prescribe the equipment prior to the patient purchasing or renting the equipment.
  • The equipment must be medically necessary for use in the patient`s home.

Some of the Durable Medical Equipment covered by Part B include:

  • Oxygen equipment (including oxygen), ventilators, aspirators, suction pumps.
  • Wheelchairs, walkers, canes, crutches, commode chairs, hospital beds.
  • Power operated vehicles (POV`s) under certain circumstances.
  • Other medically necessary equipment. 

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