Medicare Part B (Medical Insurance) Original Medicare
Outpatient services exclusions
B are routine physical examinations and related tests, eye exams, fitting of eyeglasses or contact lenses, hearing exams, fitting of hearing aids, most immunizations and routine foot care.
Hepatits B shot
Certain people with Medicare at medium to high risk for Hepatitis B are eligible. The patient pays 20% of the Medicare-approved amounts for the Hepatitis B vaccine given at a doctor's office
Barium Enema
Doctors can use this instead of a flexible sigmoidoscopy or colonoscopy. It is covered every 24 months if the patient is at high risk for colorectal cancer and every 48 months if the patient is not at high risk
certificate of medical necessity
For some equipment, Medicare also requires the doctor or one of the doctor's office staff to complete a special form and send it to Medicare to get approval for the equipment
Coinsurance
In addition to the 20% copayment or coinsurance, the patient may be required to pay an additional amount if the provider does not accept assignment.
Chiropractic services
Manual manipulation for subluxation of the spine is the only chiropractic service that is covered by Medicare. A chiropractor is defined in the Social Security Act as a physician for only one service, manual manipulation or treatment of subluxation of the spine. The patient does not need an X-ray to prove that the patient has a subluxation of the spine.
hearing and balance exams
Medicare covers these exams if the member's doctor or other health care provider orders them to see if the patient needs medical treatment. Medicare deductible and coinsurance apply. In a hospital outpatient setting, the member must also pay the hospital a copayment.
fecal occult blood test
Medicare covers this test once every 12 months
colonoscopy
Medicare covers this test once every 24 months if the patient is high risk for colorectal cancer. If the patient is not high risk for colorectal cancer, the test is covered once every 10 years, but not within 48 months of a screening flexible sigmoidoscopy.
Flexible Sigmoidoscopy
Medicare covers this test once every 48 months.
pnuemococal shot
One shot may be all that is needed. If the physician accepts assignment, Medicare pays all the cost.
ambulatory services
Part B covers services given in an Ambulatory Surgical Center for a covered surgical procedure. The patient pays 20% of the Medicare Approved Amount after meeting the annual Part B Deductible. Actual amounts may be more if doctors, health providers, or suppliers do not accept assignment. An ambulatory surgical center is a place other than a hospital that does outpatient surgery. At an ambulatory (in and out) surgery center, the patient may stay for only a few hours or for one night
Part B exclusions outpatient services
Private duty nursing; Skilled nursing home care costs over 100 days per benefit period; Intermediate nursing home care; Physician charges above Medicare's approved amount; Most outpatient prescription drugs; Care received outside the United States; Custodial care received in the home; Dental care (except dental expenses resulting from an accident only); Cosmetic surgery Orthopedic shoes; Acupuncture expenses; Expenses incurred due to a war or act of war
flu shots
The flu is a serious illness that can lead to pneumonia, and people age 50 and older are especially vulnerable to it. The flu shot is given once per flu season. Medicare pays all the cost of a flu shot if the physician accepts assignment.
limiting charge
The highest amount of money than can be charged for a Medicare-covered service by doctors and other health care providers who do not accept assignment
Part B exclusions
does not cover routine dental care or most dental procedures such as cleanings, fillings, tooth extractions or dentures. In rare cases, Medicare Part B will pay for certain dental services
Part B covered services
cover medically necessary medical and other services: doctors' services, outpatient medical and surgical services and supplies, diagnostic tests, ambulatory surgery center facility fees for approved procedures, and durable medical equipment. It also covers a second, and sometimes a third, surgical opinion for surgery that is not an emergency (in some cases), outpatient mental health care, and outpatient occupational and physical therapy including speech-language therapy
radiation therapy
covered for patients who are hospital inpatients or outpatients, or patients in freestanding clinics. In the hospital setting, Part A covers radiation therapy. In a freestanding facility, Part B covers radiation therapy. For Part B coverage, the patient pays 20% of the Medicare-approved amount after meeting the annual Part B deductible.
bone mass measurements
covers bone mass measurements ordered by a doctor or qualified practitioner who is treating a patient if the patient meets one or more of the following conditions: Women: The patient is being treated for low estrogen levels and is at clinical risk for osteoporosis, based on the patient's medical history and other findings. Men and Women: The patient's X-rays show previous osteoporosis, osteopenia, or vertebrae fractures. The patient is on prednisone or steroid-type drugs or is planning to begin such treatment. The patient has been diagnosed with primary hyperparathyroidism. The patient is being treated with a drug for osteoporosis, to see if the therapy is working. The test is covered every 24 months for qualified individuals and more frequently if medically necessary.
diabetes services
covers certain supplies if the patient has diabetes and has Medicare Part B. These covered supplies include blood sugar (glucose) monitors, therapeutic shoes, and insulin pumps. Medicare currently covers the same type of blood sugar testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies. If the patient uses insulin, the patient may be eligible for up to 100 test strips and lancets every month, and one lancet device every 6 months. If the patient does not use insulin, the patient may be eligible for 100 test strips and lancets every 3 months, and one lancet device every 6 months.
other diagnostic test
covers diagnostic tests like CT scans, MRIs, EKGs, and x-rays. Medicare also covers clinical diagnostic tests and lab services provided by certified laboratories that are participating in Medicare. Diagnostic tests and lab services are done to help the doctor diagnose or rule on a suspected illness or condition. Medicare does not cover most routine screening tests, like checking a patient's hearing.
mamogram screening
covers mammogram screening once every 12 months (11 full months must have gone by from the last screening) for all women with Medicare age 40 and older. The patient can receive one baseline mammogram between ages 35 and 39. Medicare covers digital technologies for mammogram screenings. Patient cost in the Original Medicare Plan is 20% of the Medicare-approved amount with no Part B deductible.
prostate cancer screening
covers screening tests once every 12 months for all men age 50 and older with Medicare (coverage begins the day after the patient's 50th birthday)
colorectal cancer screening
covers several colorectal cancer screening tests. All people age 50 and older with Medicare are covered. There is no minimum age for having a colonoscopy. Screening tests can help prevent colorectal cancer by finding pre-cancerous polyps so they can be removed before they turn into cancer.
ambulance transportation
covers some nonemergency ambulance transportation. This service is limited. Medicare may cover a nonemergency trip if the patient is confined to a bed and has a statement from the doctor saying that ambulance transportation is necessary because of the patient's medical condition. Even if the patient is not confined to a bed, Medicare may still cover a nonemergency ambulance trip if the patient has a statement from a doctor. Ambulance services are covered when it is medically necessary for the patient to be transported by ambulance to a hospital or skilled nursing facility, and transportation in any other vehicle would endanger health. Generally, transportation from a hospital or SNF is not covered. If the care needed is not available locally, Medicare helps pay for necessary ambulance transportation to the closest facility outside the local area that can provide the care needed. If the patient chooses to go to another facility farther away, Medicare payment is based on how much it would cost to go to the closest facility. All ambulance suppliers must accept assignment.
heart transplants
covers transplants of the heart, lung, kidney, pancreas, intestine/multivisceral, bone marrow, cornea, and liver under certain conditions and, for some types of transplants, only at Medicare-approved facilities. Transplant coverage includes necessary tests, labs, and exams before surgery for the patient and the organ donor, follow-up care for the patient and the live donor, and procurement of organs and tissues.
deductible
deductible applies, the insured must pay all costs until the yearly Part B deductible is met ($185 in 2019) before Medicare begins to pay its share. After the deductible is paid, the insured typically pays 20% of the Medicare approved amount for services rendered.
rural health clinic
established in 1977. The intent is to increase availability and accessibility of primary health care services to rural areas. Reimbursement is available from Medicare and Medicaid. The clinic must be located in a federally designated rural area defined by the Bureau of Census as non-urban. Medicare and Medicaid reimbursements are available to qualified Rural Health Clinics for covered health care services furnished by nurse practitioners, physician assistants, certified nurse midwives, physicians, clinical psychologists, and/or clinical social workers. Not covered as a Rural Health Services are durable medical equipment, ambulance services, prosthetic devices, speech, and occupational therapy providers. Medicare reimburses an independent Rural Health Clinic 80% of its all-inclusive payment. Patient is responsible for 20%
Pap smear and pelvic examination
helps pay for a Pap test, pelvic exam, and clinical breast exam once every 24 months. For some women, Medicare helps pay for a Pap test, pelvic exam, and clinical breast exam once every 12 months. This includes women who are of an age to have children and have had an abnormal Pap test within the past 36 months, or are at high risk for cervical or vaginal cancer. Medicare considers the patient at high risk for cervical or vaginal cancer if the patient has not had any Pap tests within the last 7 years, has had less than 3 normal Pap tests in the last 7 years, is the daughter of a woman who took diethylstilbestrol (DES) during pregnancy, begins having sexual intercourse before the age of 16, has had 5 or more sexual partners in her life, or has a history of sexually transmitted disease
Yearly "wellness" visit
in addition to a "Welcome to Medicare" preventive visit available during the first 12 months, Medicare Part B covers annual "wellness" visit during which the insured and the provider can develop or update a personalized plan for disease prevention. There is no out-of-pocket cost for the insured for these visits if the doctor or other qualified health care provider accepts assignments. If a doctor or a health care provider performs additional tests or services during the same visit that are not covered under this preventive benefit, the insured may have to pay coinsurance. Part B deductible may also apply. Clinical laboratory services, including blood tests, urinalysis, and some screening tests, are covered for long-term nursing home residences.
home health care
limited to reasonable and necessary part-time or intermittent skilled nursing care and home health aide services. Home health services are provided under Medicare Part A unless the patient only has Medicare Part B. The patient is eligible for home health care if the doctor decides the patient needs care in their home and makes a plan for care at home Patients need at least one of the following: Intermittent (and not full time) skilled nursing care; Physical therapy or speech language pathology services; or Continued need for occupational therapy, and the patient is homebound
Assignment
means an agreement by a doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount approved for the service by Medicare, and not to bill the member for any more than the Medicare deductible and coinsurance.
homebound
means the patient is normally unable to leave home and that leaving home is a major effort. When the patient leaves home, it must be infrequent, for a short time. The patient may attend religious services. The patient may leave the house to get medical treatment, including therapeutic or psychosocial care. The patient can get care in an adult day care program that is licensed or certified by the state or accredited to furnish adult day care services, and the home health agency caring for the patient is approved by the Medicare program. Medicare pays 100% of the Medicare approved amount for home health visits.
kidney dialysis
part b covers some kidney dialysis services and supplies, including inpatient dialysis treatment, certain home support services and certain drugs for home dialysis, and topical anesthetics. covers maintenance dialysis treatments Medicare covers the cost of self-dialysis and home dialysis equipment and supplies (like alcohol, wipes, sterile drapes, rubber gloves, and scissors).
outpatient medical services and supplies
pays for most Medicare Part B outpatient services received at a hospital or community mental health center under the outpatient prospective payment system. An outpatient service is any service received in one day (24 hours). This includes services like X-rays (radiology), stitches for a cut, an emergency room visit, and getting a cast.
vaccinations
provides coverage to all eligible enrollees for flu shots, pneumococcal shots, and Hepatitis B shots.
portable diagnostic test
such as chest X-rays, performed in nursing facilities on nursing facility residents are covered by Medicare only when the patient is enrolled in Medicare Part B. Nursing facilities are required to perform periodic assessments of residents in order to develop an individualized plan of care in conjunction with the attending physician. Therefore, Medicare will cover diagnostic tests and X-rays on nursing facility residents when they address medical problems identified either through the mandated periodic assessments or in connection with episodes of illness indicating a change in condition. The most common situations requiring chest X-ray in these facilities are signs and symptoms suggesting a pulmonary condition or heart failure. Portable X-rays are limited to those patients whose clinical condition.
Blood deductible
will cover all but the first 3 pints of blood. Part B covers blood received as an outpatient and in a free standing Ambulatory Surgical Center. The patient pays for the first 3 pints of blood.
eyeglasses
will cover one pair of eyeglasses with standard frames or one set of contact lenses after cataract surgery that implants an intraocular lens. The insured must pay 20% of the Medicare-approved amount, and the Part B deductible.
