Medicare Part B: Eligibility, Coverage, and Cost

Medicare Part B is one portion of the United States federal government program that offers health insurance to seniors and other qualifying individuals.  Part B is:

• available to US citizens age 65 and above, and certain people with disabilities or qualifying diseases
• medical insurance that covers doctor visits, outpatient services, and preventative care
• subject to a $226 deductible, as well as various coinsurance/copay costs (usually 20% of Medicare-approved services)
• offered at a monthly premium that is standardized based on income level

Medicare Part B Eligiblity

There are four ways to qualify for Medicare Part B:

• When you turn 65, if you qualify for premium-free Medicare Part A (due to satisfaction of work requirements), you are also eligible for Part B. In this scenario, you will only pay a monthly premium for Medicare Part B.
• When you turn 65, if you do not qualify for premium-free Part A, you must live in the U.S. and show proof of citizenship or legal permanent residency. You will pay a monthly premium for Part A in addition to your Part B premium.
• If you receive disability benefits from the Social Security office or the Railroad Retirement Board (RRB) for at least twenty-four months due to permanent disability, you are eligible for Part B. You are also eligible for Part A, regardless of age.
• If you receive a diagnosis of end-stage renal disease, you are immediately eligible for both Parts A and B.

In most cases, you will need to enroll in Medicare Part A to qualify for Medicare Part B. Part A is the hospital insurance that covers inpatient hospital care, skilled nursing facility care, home health care, and hospice care. Part B will cover medical expenses and outpatient care.

What Medicare Part B Covers

Medicare Part B covers two types of services: medically necessary care and preventative care.

Some examples of services that are covered include:

• Doctor services
• Emergency room services
• Clinical research
• Laboratory work
• Imaging and other diagnostic screenings
• Emergency transportation (ambulance)
• Durable medical equipment (wheelchairs, oxygen tanks, etc)
• Chemotherapy
• Mammograms (screening)
• Inpatient and outpatient care for mental health
• Partial hospitalization for mental health
• Vaccines
• Kidney dialysis
• EKG Screening
• Occupational therapy
• Physical therapy
• Hepatitis B Shots
• HIV Screening
• Home Health Services
• Flu shots
• Foot Exams and Treatment (diabetes-related)
• Glaucoma Tests
• Hearing and Balance Exams
• Pap Tests and Pelvic Exams (includes clinical breast exam)
• Acupuncture (for treating chronic low back pain)

The fastest way to determine if testing, services, or medical equipment are eligible for Part B coverage is to use the search feature at Medicare.gov. Enter the item or service in question to see whether it is covered by Part B. Your doctor should also have information on covered services.

What Medicare Part B Doesn't Cover

Several services are not covered by Part B, including:

• Long-term care
• Dentures or dental implants
• Cosmetic surgery
• Routine foot care (not diabetes-related)
• Hearing exams for hearing aid fittings
• Most eye exams
• Most dental care
• Full prescription drug coverage

How Much Does Medicare Part B Cost?

The cost of Medicare Part B can be broken down into three categories:

• monthly premium
• annual deductible
• Part B copayments/coinsurance

Monthly premium:  A paid monthly premium is required to keep your Medicare Part B policy active. For 2023, the standard Part B premium is $164.90. Most people pay the standard Part B premium amount; however, the rate is standardized by the government and can change every year. Individuals who earn more than $97,000 a year or couples who earn more than $194,000 a year are required to pay an Income Related Monthly Adjustment Amount, or IRMAA. There are six tiers with their own monthly premium based on income and tax filing status. Rates for beneficiaries with higher income may range from $238.10 to $578.30.

Annual deductible:  For 2023, the Part B deductible is $226, which means you are responsible to pay for the first $226 of covered services before Part B will begin covering your claims. The deductible for Medicare Part B is also standardized, which means all beneficiaries pay the same deductible every year. The deductible doesn’t change regardless of income.

Copayments / Coinsurance – Once you meet your annual deductible, Medicare will start sharing the cost of covered services with you. In most cases, Medicare pays 80% of Medicare-approved costs, and you will pay the remaining 20% coinsurance. Medical professionals who accept Medicare assignments should only charge the prices approved by Medicare. Your coinsurance and copayment costs will depend on how often you visit the doctor and what services or medical equipment you need.

How to Enroll in Medicare Part B

You may choose any of the following options to enroll in Medicare Part B:

• Apply online (this is the fastest option).  As you prepare to apply, use the Medicare Documentation Checklist to gather the information you need in order for the process to go smoothly.
• Call the Social Security Administration toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
• Visit your local Social Security office. The agency has a Social Security office locator on its website.

Note: If you receive disability benefits from Social Security or the Railroad Retirement Board (RRB) for a total of 24 months, you will be automatically enrolled in Medicare Part A when you turn 65. You may also qualify for Original Medicare coverage before turning 65 if you are permanently disabled or have been diagnosed with end-stage renal disease.

If you aren’t receiving disability benefits from Social Security or the RRB, your first and best chance to enroll in Medicare Part B is your Initial Enrollment Period. Your IEP lasts for seven months: the three months before your 65th birthday, the month of your birthday, and the three months after your birthday. For example, if you turn 65 on May 5, your initial enrollment period will start on February 1 and end on August 31.

If you want your Part B health insurance to start when you turn 65, you should apply during the first three months of the initial enrollment period. Applying during your birthday month or after will cause a delay in coverage.

• Other Enrollment Periods

  General Enrollment Period: January 1st to March 31st each year

  If you miss your initial enrollment period, then you will have to wait until the general enrollment period the following year (unless you qualify for a special enrollment period – see below). Your start date for coverage will be July 1st in this case.

  Special Enrollment Periods:

  If you don’t enroll in Medicare Part B during your initial enrollment period, you may qualify for a special enrollment period. This short period allows you to enroll without paying a late enrollment penalty (see below). However, it’s only available for people with qualifying circumstances. The most common reason people might delay Part B enrollment is that they already have full health care coverage through an employer when they turn 65.  In this case, your special enrollment period will begin when your employer coverage ends.

Note: You may pay a late enrollment penalty that equals 10% of the Part B premium for every year you were eligible for benefits but did not enroll. For example, if you wait three years to enroll in Medicare Part B and don’t qualify for a special enrollment period, you could pay 30% more for your premium than you would have paid if you enrolled when first eligible.

FAQ's:

• How Long Does It Take To Get Medicare Part B After Applying?

  Your coverage start date depends on when you enroll in Medicare Part B. Here is a guide to help you determine your most likely Part B coverage start date based on your date of enrollment.

   

  For example, let’s say Jack is turning 65 in June.

   

  If Jack enrolls in March, April, or May, he will be covered June 1st.  If his actual birthdate is June 1st, he will be covered May 1st.

  If Jack enrolls in June, he will be covered July 1st.

  If Jack enrolls during July, August, or September, he will be covered the 1st day of the following month.

  If Jack delays his enrollment past his initial enrollment period, and instead enrolls during a special enrollment period, he will be covered the first day of the month following receipt of his enrollment request

  If Jack waits to enroll during the general enrollment period (considered a late enrollment) of January 1st to March 31st, he will be covered on July 1st of the year he applied.

   

  Please note: this is not a guarantee of coverage dates; it is merely a guide for explanation purposes. 

  Source: Medicare.gov

• Is Medicare Part B Eligibility Based on Income?

  The amount you pay for the Part B premium is based on income, but general eligibility is not. If you’re qualified to enroll in Medicare Part A, you are also eligible for Part B. You may, however, pay more per month if your income is above designated thresholds.

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Article Resources

• What Does Medicare Part B Cover?
• What Medicare Part B Doesn’t Cover
• Medicare Part B Eligibility
• Medicare Part B Monthly Premium
• When Can I Enroll in Medicare Part B?