There are many layers to the federal Medicare program. Let us help you figure out where to begin. We'll break down Medicare into manageable pieces, so you know if you qualify for Medicare coverage, what coverage is available in your area, and how to get enrolled in a plan that fits your needs.

Medicare Part B

Medicare Part B is medical insurance that helps pay for medical expenses relating to your doctors' services, also known as outpatient expenses. While most Americans will receive Part A without paying a premium, Part B is optional and enrollees must pay a monthly premium for the coverage. Enrollment in Part B is necessary, however, if you would like to enroll in additional optional benefits, such as prescription drug plans (Part D), Medigap plans, or Medicare Advantage plans.

Part B costs

You pay a premium each month for Medicare Part B (Medical Insurance). Most people will pay the standard premium amount. However, if your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you may pay an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium.

How much does Part B cost?

Most people pay the Part B premium of $104.90 each month in 2013 and 2014.

You pay $147 per year for your Part B deductible in 2013 and 2014.

Some people automatically get Part B.

If you don't sign up for Part B when you're first eligible, you may have to pay a late enrollment penalty.

If your modified adjusted gross income as reported on your IRS tax return from 2 years ago (the most recent tax return information provided to Social Security by the IRS) is above a certain amount, you may pay more.

Part B premiums by income

If your yearly income in 2011 (for what you pay in 2013) or 2012 (for what you pay in 2014) was You pay (in 2013 and 2014)
File individual tax return File joint tax return File married & separate tax return
$85,000 or less $170,000 or less $85,000 or less $104.90
above $85,000 up to $107,000 above $170,000 up to $214,000 Not applicable $146.90
above $107,000 up to $160,000 above $214,000 up to $320,000 Not applicable $209.80
above $160,000 up to $214,000 above $320,000 up to $428,000 above $85,000 and up to $129,000 $272.70
above $214,000 above $428,000 above $129,000 $335.70

What's covered?

Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.

If you're in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.

Part B covers 2 types of services

  • Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
  • Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.

Part B covers things like:

  • Clinical research
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
    • Inpatient
    • Outpatient
    • Partial hospitalization
  • Getting a second opinion before surgery
  • Limited outpatient prescription drugs

2 ways to find out if Medicare covers what you need

  1. Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that's usually covered and your provider thinks that Medicare won't cover it in your situation, you'll have to read and sign a notice saying that you may have to pay for the item, service, or supply.
  2. Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors

  1. Federal and state laws.
  2. National coverage decisions made by Medicare about whether something is covered.
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.