Welcome to Medicare University
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.
Cost
You will pay a monthly premium for your Medicare Part B coverage. When you use services you will also pay a deductible and coinsurance.
In 2008, people with higher incomes will pay higher premiums for Part B. Approximately 4 percent of Medicare Part B enrollees will pay a higher Part B premium based on their income. Most people on Medicare will pay $96.40 a month for Part B in 2008. That's up $2.90 from 2007. Higher-income people will pay even more.
| 2006 Tax Return Income (Individual) | 2006 Joint Tax Return Income (Married Couples) | 2008 Monthly Part B Premium |
|---|---|---|
| Up to $82,000 | Up to $164,000 | $96.40 |
| $82,001 to $102,000 | $164,001 to $204,000 | $122.20 |
| $102,001 to $153,000 | $204,001 to $306,000 | $160.90 |
| $153,001 to $205,000 | $306,001 to $ $410,000 | $199.70 |
| Over $205,000 | Over $410,000 | $238.40 |
If you're on Medicare before January 1, 2008, you'll be told at the end of 2007 about the 2008 rates, as well as any related changes in your Social Security benefits. If you enroll after then and must pay the higher premium, you'll hear shortly after enrolling.
In 2008, if you use Part B-covered services, you will pay a deductible. The deductible is the same for all people with Part B coverage. After paying the deductible, you will pay coinsurance of 20% of the Medicare-allowed payment to the Part B health care provider. The 2008 Part B deductible is $135, up $4 from 2007.
Covered
Medicare Part B helps cover many health care services you need to maintain your health. It is important to understand the types of doctor visits and services Medicare Part B covers.
Medicare Part B will pay for:
- Doctors' services (not routine physical exams except for a "Welcome to Medicare" one-time physical exam within the first six months you have Part B)
- Outpatient medical and surgical services and supplies
- Diagnostic tests
- Ambulatory surgery center facility fees for approved procedures
- Durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers).
- A second, and sometimes a third, surgical opinion for surgery that isn't an emergency (in some cases)
- Outpatient mental health care
- Outpatient occupational and physical therapy, including speech-language pathology. (These services are also covered for long-term nursing home residents.)
Additional Services
- Ambulance services - when it's medically necessary to be transported to a hospital or skilled nursing facility, and transportation in any other vehicle would endanger your health
- Chiropractic services - manipulation of the spine to correct a when one or more of the bones of your spine moves out of position
- Clinical trials - routine costs if you take part in a qualifying clinical trial (doesn't cover the costs of experimental care, such as the drugs or devices being tested in a clinical trial)
- Diabetic Self-Management Training - for certain people with Medicare at risk for complications from diabetes. Your doctor or other health care provider must request this service
- Diabetic supplies - glucose testing monitors, blood glucose test strips, lancet devices and lancets, glucose control solutions, and therapeutic shoes (in some cases) Syringes and insulin aren't covered (unless used with an insulin pump) unless you join a Medicare prescription drug plan (hotlink to Part D page).
- Durable medical equipment - items such as oxygen, wheelchairs, walkers, and hospital beds needed for use in the home
- Emergency room services
- Eyeglasses - one pair of eyeglasses with standard frames after cataract surgery that includes implanting an intraocular lens
- Foot exams and treatment - if you have diabetes-related nerve damage and meet certain conditions
- Hearing and balance exams - if your doctor orders them to see if medical treatment is needed (hearing aids and exams for fitting hearing aids aren't covered)
- Kidney dialysis services - kidney dialysis, and services and supplies, either in a facility or at home
- Long-term care - only skilled care given in a certified skilled nursing facility or in your home (not custodial care)
- Medical nutrition therapy services - for people who have diabetes, or for people who have kidney disease (unless you are on dialysis) with a doctor's referral for three years after a kidney transplant
- Mental health care - inpatient or outpatient; contact Medicare to understand certain limits and conditions that apply
- Practitioner services - such as those provided by clinical social workers, physician assistants, and nurse practitioners
- Prescription drugs - Medicare Part B covers limited prescription drugs, like certain injectable cancer drugs.
- Prosthetic/orthotic items - arm, leg, back, and neck braces; artificial eyes; artificial limbs (and their replacement parts); breast prostheses (after mastectomy); prosthetic devices needed to replace an internal body part or function (including ostomy supplies, and parenteral and enteral nutrition therapy) Second surgical opinions - covered in some cases
- Second surgical opinions - covered in some cases
- Smoking cessation counseling - inpatient or outpatient services, up to eight face-to-face visits during a 12-month period if you are diagnosed with a smoking-related illness
- Surgical dressings - if required for treatment of a surgical or surgically treated wound
- Telemedicine - services in some rural areas that help connect patients and doctors via technology
- Tests - X-rays, MRIs, CT scans, EKGs, and some other diagnostic tests if medically necessary
Contact Medicare for additional information about these services and what your cost-sharing responsibility will be.
Preventive Services
Prevention is an important part of staying healthy. According to the federal government, Medicare Part B covers these preventive services:
"Welcome to Medicare" Physical Exam (One-time)
Medicare covers a one-time review of your health by your physician, as well as education
and counseling about the preventive services you need, including certain screenings
and shots. Referrals for other care, if you need it, are also covered. You must
have the physical exam within the first six months you have Medicare Part B.
Bone Mass Measurements
These measurements help determine if you are at risk for broken bones. Medicare
covers these measurements once every 24 months (more often if medically necessary)
for people with Medicare at risk for osteoporosis. Your doctor will determine if
you are at risk.
Cardiovascular Screenings
Medicare covers screening tests for cholesterol, lipid, and triglyceride levels
every five years. This may help you prevent a heart attack or stroke by understanding
if you are at elevated risk.
Colorectal Cancer Screening
Medicare Part B will cover one or more of the following colorectal screening tests
(*Age 50 or older):
- Fecal Occult Blood Test
- Flexible Sigmoidoscopy
- Screening Colonoscopy
- Barium Enema
These tests help find precancerous growths so they can be removed and prevent cancer. They also help find colorectal cancer early, when treatment is most effective. You and your doctor will decide how often you need these tests, depending on your risk for this cancer.
Diabetes Screenings
Medicare covers tests to check for diabetes. These tests are available if you have
any of the following risk factors:
- High blood pressure
- Dyslipidemia (history of abnormal cholesterol and triglyceride levels)
- Obesity
- A history of high blood sugar
Medicare also covers these tests if you have two or more of the following characteristics:
- Age 65 or older
- Overweight
- Family history of diabetes (parents, brothers, sisters), and a history of gestational diabetes (diabetes during pregnancy)
- Delivery of a baby weighing more than 9 pounds
Flu Shots
Medicare Part B covers flu shots in the fall or winter to help prevent influenza,
or flu virus. Flu shots are particularly important for people 65 and older, who
are more at risk for severe illness and fatality due to flu.
Glaucoma Tests
These tests help find the eye disease glaucoma. Medicare Part B covers these tests
once every 12 months for people at high risk for glaucoma.
Hepatitis B Shots
These three shots help protect people from getting Hepatitis B. Medicare Part B
covers these shots for people at high or medium risk for Hepatitis B.
Pap Test and Pelvic Exam (includes clinical breast exam)
These exams check for cervical and vaginal cancers. Medicare covers these exams
every 24 months for all women with Medicare and once every 12 months for women with
Medicare at high risk. Your doctor will help determine if you are at high risk.
Pneumococcal Shot
This shot helps prevent pneumococcal infections. Medicare covers this shot for all
people with Medicare. Most people only need this shot once in their lifetime. Talk
with your doctor to find out if you need this shot.
Prostate Cancer Screening
Medicare Part B covers a digital rectal exam and Prostate Specific Antigen (PSA)
test once every 12 months for all men over age 50. This test indicates X and Y.
Screening Mammograms
Medicare covers mammograms once every 12 months for all women with Medicare age
40 and older. These tests check for breast cancer before you or your doctor may
be able to feel it.
For more specific information on these services, here is an overview from the Center for Medicare Services.
Home Healthcare
If you need clinical laboratory services, Medicare Part B will pay for:
- Blood tests
- Urinalysis
- Some screening tests
If you need home health care, Medicare Part B will pay for:
- Reasonable and necessary part-time or intermittent skilled nursing care and home health aide services
- Physical therapy, occupational therapy, and speech-language pathology that are ordered by your doctor and provided by a Medicare-certified home health agency
- Medical social services, such as getting professional help in arranging needed follow-up care by referral to health-care resources
- Durable medical equipment and other medical supplies (such as wheelchairs, hospital beds, oxygen, and walkers)
If you need outpatient hospital services, Medicare Part B will pay for:
- Hospital services and supplies received as an outpatient as prescribed by your doctor
