Are you nearing age 65? If so, you are close to becoming eligible for Medicare. Medicare is health insurance from the American government for seniors 65 years and older and others who qualify earlier due to disability. There is a specific time to enroll in Medicare called the Initial Enrollment Period, which begins three months before your 65th birthday month and ends three months after. Before this enrollment period, you should become familiar with your future health coverage. Keep reading for an overview of Medicare Part B coverage.
What does Medicare Part B cover?
Medicare Part B covers your care at an outpatient facility, such as your doctor’s office, urgent care, and emergency room. So, any services you receive as a non-inpatient will fall under Medicare Part B. A few services Medicare Part B covers are:
· Doctor’s visits
· Ambulance rides
· Durable medical equipment
· Chemotherapy and radiation
· Outpatient surgery
· Lab work
· Home health care
· Select vaccines (i.e., Influenza, Pneumonia, Hepatitis B, COVID-19)
Remember that Medicare covers medically necessary services to diagnose or treat an injury, illness, or disease. If you receive a service that is not medically necessary, then Medicare will deny coverage. Let’s look at an example!
Sally has not been feeling well, so she has the idea to visit a lab and get her blood drawn to see if there is anything off balance. Medicare would deny the claim in this case because her doctor did not order the lab work. Now, let’s say Sally schedules a visit with her doctor, and her doctor orders the blood work and deems it medically necessary to diagnose a health condition; Medicare should cover the cost after she has met the Part B deductible ($233 in 2022).
When it comes to Part B coverage, it all depends on the proper coding and Medicare guidelines.
Preventative services covered by Part B
Medicare does not cover all services in full. For many Part B services, you will first be subject to the Part B deductible mentioned above. After you pay the Part B deductible, Part B will cover 80% of the Medicare-approved charges, and you will pay a 20% coinsurance (unless you have secondary coverage). But, there are many preventative services that Medicare covers in total.
Here are a few of them:
· Welcome to Medicare during the first 12 months of Medicare
· Annual Wellness Visit once a year after being on Medicare for 12 months
· Screening mammogram every 12 months
· Colonoscopy once every 24 months if high risk
· Diabetes prevention (24 sessions)
· Bone density measurements once every 24 months
· Prostate cancer screening every 12 months
· Cervical cancer screening every five years
Medicare covers just a few preventative services, but you can find a chart of other covered services here. Now, Medicare will not cover a diagnostic exam at 100%. For instance, if you have a mammogram and it becomes a diagnostic mammogram, you will be subject to the Part B deductible and coinsurance.
What does Part B not cover?
Although Part B covers hundreds of different services, there are a few that Medicare will deny, no matter what. Medicare will not cover cosmetic services like Botox, a nose job, or non-medically necessary implants. Medicare also does not cover routine dental, vision, and hearing services. So, if you visit the dentist for teeth cleaning, Medicare will deny coverage.
But, this does not mean Medicare would not cover medically-necessary surgery for these things. For example, Medicare will cover cataract surgery if you develop cataracts. Or let’s say you are in a car wreck and break your nose; Medicare should pay for your surgery.
Medicare Part B covers your outpatient care but does not fully cover every medical service. Many Medicare beneficiaries purchase a Medigap or Medicare Advantage plan for cost-sharing help. Contact a reputable Medicare broker to shop and compare Medicare plans to ensure you find the most cost-effective method in your area!
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