Medicare Part B

Medicare Part B Supplementary Medical Insurance (SMI) Benefits

Medicare Part B, covers, along with many other services:

  • Physician and surgeon services
  • Outpatient services
  • Medical laboratory fees
  • Ambulance transportation, when other means of transport are unsafe
  • Limited outpatient psychiatric care
  • Screening and prevention service, including breast and prostate cancer screening
  • Prosthetic devices

Excluded Part B Coverage

Items not covered under Part B include, but are not limited to:

  • Routine physical examinations (exception is coverage for a one-time, initial physical exam for those eligible for Medicare, started in 2005)
  • Routine eye or hearing exams, eyeglasses or hearing aids
  • Dental care and dentures (with few exceptions)
  • Certain immunizations
  • Chiropractic services, except to treat subluxations of the spine identified by x-ray
  • Full-time, in-home, private nursing care
  • Homemaker services provided by a friend of relative
  • Services not medically necessary

Patient’s Financial Responsibilities under Part B

After satisfying a flat $135 annual deduction (in 2009, the amount may change in 2010 and beyond) that represents the first $135 in Medicare’s approved amounts for covered services, Medicare typically pay s80 percent of its approved amount. Patients are responsible for 20 percent of Medicare’s approved amount. Exceptions to the 80/20 rule exist for some prevention and screening services and some outpatient hospital services. Medicare’s approved amount for a particular Part B service or item normally is based on a fee schedule, and approved amounts for the same services or items may vary around the country.

The Part B annual deductible increases each year by the same percentage as the Part B premium. The Congressional Budge Office estimates that the deductible will increase to $166 by 2013.

No upper limit of stop loss (maximum out-of-pocket amount) applies in the Original Medicare program. This stands in contrast to many Medicare Advantage plans and to most commercial health insurance plans, under which an annual out-of-pocket limit protects those insured.

Original Medicare: Assignment

Medicare Part B has a claim filing procedure called accepting assignment that helps control seniors’ out-of-pocket costs and expedites payments to physicians and other providers. When seniors choose their physicians or suppliers they should always ask if they accept assignment. Providers who accept assignment agree to charge no more for their services than Medicare’s approved amount. Some providers also enter formal agreements with Medicare to accept assignment in all cases. They are called Medicare Participating Providers. Others can accept assignment on a case-be-case, or claim-by-claim, basis.

Physicians who do not accept assignment are allowed to charge up to 15 percent more than Medicare’s approved amount. This is often referred to as an excess charge. Providers who accept assignment help seniors eliminate this excess charge. Nationally, physicians accept assignment for nearly 90 percent of Part B claims.

Note that durable medical equipment and supply providers are not limited to 15 percent in excess charges. Their excess charges may be even higher, making it even more important to find providers who accept assignment. When seniors use the services of providers who do not accept assignment they must pay for the care and wait for Medicare to reimburse them. Physicians and other Part B providers are required to file all claims with Medicare on behalf of their patients, whether or not the provider accepts assignment.

All Medigap insurance polices sold after 1991 cover 20 percent coinsurance charge. Some also cover all or part of the excess charge. Assignment applies only to Original Medicare. It does not apply to Medicare Advantage plans, where co-payments are the norm for each physician visit.

When Providers Must Accept Assignment

Some health care providers who are not medical doctors, such as medical social workers, must accept assignment for their services. In addition, doctors, suppliers, and pharmacies must accept assignment:

  • For lab tests covered by Medicare
  • For seniors enrolled in Medicaid if the state they live in helps pay their health care cost
  • For Medicare-covered drugs and biologicals (such as serums and vaccines) that are billed to Medicare’s claim processor (durable medical equipment regional carriers, known as DMERCs). An example is the medicine used in a nebulizer for a person with asthma
  • For Medicare-covered ambulance services
  • For Medicare-covered drugs and supplies provided by a pharmacy or other supplier

Some other providers also must agree to always accept the amount that Medicare pays as payment in full. Seniors do not have to ask them if they accept assignment. These providers include:

  • Hospitals
  • Skilled nursing facilities
  • Home health agencies and hospices
  • Comprehensive outpatient rehabilitation facilities
  • Providers of outpatient physical and occupational therapy or speech pathology services

Seniors who get Medciare-covered prescription drugs or supplies should make sure that the pharmacy or supplier is enrolled in Medicare. If not, Medicare will not pay. All enrolled pharmacies must accept assignment for Medicare-covered prescription drugs or biologicals. Beneficiaries have to pay only their 20 percent coinsurance.

Finding Providers Who Accept Assignment

Seniors should ask their physicians and other health providers whether they accept assignment. In addition, Medicare carries (companies under contract with Medicare to process Part B claims) can tell beneficiaries which physicians and other medical providers fit this category. DMERCs can tell them which medical equipment suppliers accept assignment.

Seniors can find the phone numbers for their carriers and DMERCs in several ways:

  • Look on the Medicare Summary Notice issued by a Medicare carrier or DMERCs as a record of its coverage decision and payment on a claim
  • Call 1-800-MEDICARE (1-800-633-4227); TTY users should call 1-877-486-2048
  • Visit http://medicare.gov on the web
  • Read “Where to Get your Medicare Questions Answered,” a section of the Medicare & You handbook that each enrollee receives

The Centers for Medicare & Medicaid Services (CMS has made information available at http://medicare.gov, including helpful directories. The site’s Participating Physician Directory locates physicians who accept assignment. This tool contains the names, specialties, and contact information of physicians who agree to accept assignment in call cases. The directory also contains detailed physician information such as a board certification, medical school, year graduated, gender, foreign language abilities, and hospital affiliations. The site’s Supplier Directory identifies providers of durable medical equipment and covered medical supplies and provides their contact information. You can also go to the CMS website for more information about Medicare: http://cms.gov.

Private Contracts

Assignment does not apply to agreements made between seniors and providers who do not give services through Medicare. Under these private contracts:

  • Medicare will not pay the doctor or patient for services.
  • Seniors have to pay whatever a doctor charges, and there is no limit to what can be billed.
  • No claim can be submitted for the service, and Medicare will not pay if a claim is submitted.
  • Medicare supplement insurance policies will not pay anything for services under private contracts.
  • Most other insurance plans will not pay for the service.

You should be aware that if a senior receives health care that is not eligible for Medicare coverage, the physician must have the patient sign a statement that states that Medicare benefits will not apply. If this does not occur, the senior is not responsible for charges related to the procedure.

The information above is reprinted from Working with Seniors: Health, Financial and Social Issues with permission from Society of Certified Senior Advisors® . Copyright © 2009. All rights reserved. www.csa.us