Medicare Part B helps cover medically necessary services like doctors’ services, outpatient care, home health services, durable medical equipment, and preventive services. It specifically covers health care services and supplies that Part A typically doesn’t cover, like certain types of home health care and doctor services.
Anyone who is eligible for Medicare and enrolls in Part B pays a monthly premium for this coverage. In 2023, the standard monthly premium is $164.90. Those who don’t enroll when they’re first eligible may have to pay a late enrollment penalty for as long as they have Part B.
Covered Services for Medicare Part B Eligibility
Some key services covered under Medicare Part B include:
- Doctor services – This includes most doctor and other health care provider services, including office visits, some telehealth services, and annual wellness visits.
- Outpatient care – This includes things like outpatient hospital services like emergency room visits, observation stays, outpatient surgeries, and lab tests.
- Home health services – Part B covers medically necessary part-time or intermittent skilled nursing care, home health aide services, and physical therapy, speech-language pathology services, and occupational therapy provided in your home.
- Durable medical equipment (DME) – Walkers, wheelchairs, insulin pumps, crutches, blood testing supplies, and hospital beds when used in the home are examples of durable medical equipment covered under Part B.
- Preventive services – Specific preventive services are covered at no cost when the doctor accepts Medicare assignment, like screenings for breast, prostate and colorectal cancers, diabetes screening, and flu and pneumonia vaccines.
- Ambulance services – Part B covers medically necessary ambulance trips when transportation in any other vehicle could endanger your health.
Medicare Summary Notice (MSN)
The MSN is an important document sent quarterly to those with Original Medicare. It lists all care and services billed to Medicare along with explanations of payments made and your financial liability. The MSN helps verify claims were properly processed and paid and identifies any denied services requiring an appeal.
Reasons for Denial
There are a few key reasons why someone may not have Medicare Part B coverage:
- Not enrolled in Medicare – To get Part B, you must be enrolled in Medicare Parts A and B. Those not already receiving Social Security retirement benefits at age 65 must proactively enroll.
- Enrollment period missed – There is a 7-month initial enrollment period surrounding your 65th birthday. Missing this window results in a late enrollment penalty unless a Special Enrollment Period applies.
- Income too high – Higher earners pay a higher standard Part B monthly premium amount due to Income Related Monthly Adjustment Amounts (IRMAA). Some opt out due to premium costs.
- Failure to pay premiums – Part B coverage can be terminated if premium payments are delinquent for 12 continuous months. Reinstatement requires repayment of owed premiums.
- Covered by a government or private employer plan – Those with “creditable” prescription drug coverage from a current job may delay Part B without penalty.
How to Handle Denied Claims
If a Medicare claim is denied in full or in part, the first step is to understand why by carefully reviewing explanation of benefits. Common denial reasons include:
- Service deemed non-covered by Medicare rules
- Required documentation missing
- Claim timely filing deadline missed
For denied or incorrectly processed claims, submit an appeal with any additional information within 120 days of the MSN date. Contact the supplier, state health insurance assistance program, or 1-800-MEDICARE for claims assistance. An appeal may result in a favorable decision to reverse the denial.
As a last resort, those dissatisfied after completing the four-level appeals process may request an ALJ hearing or judicial review. It’s important not to ignore denied claims and instead pursue potential reimbursement through formal redetermination.
In summary, failure to enroll or maintain Part B coverage through premium payments as required are typical reasons why an individual may lack this important Medicare benefit at some point. Following up on denied claims can help resolve incorrect coverage decisions.
We’re Here to Help
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Why would someone not have Medicare Part B?
A: There are several reasons why someone might not have Medicare Part B, including being covered by a group health plan based on current employment, being covered by a group health plan based on a spouse’s current employment, or having coverage through Indian Health Services.
Q: When am I first eligible for Medicare Part B?
A: You are first eligible for Medicare Part B during your Initial Enrollment Period, which is the seven-month period that begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65.
What are the eligibility criteria for Medicare Part B enrollment?
You are eligible for Medicare Part B if you are 65 or older, a United States citizen, or a permanent legal resident who has lived in the United States for at least five continuous years, and you or your spouse have worked long enough to be eligible for Social Security or railroad retirement benefits.
Can I delay enrolling in Medicare Part B if I am receiving Social Security benefits?
If you are receiving Social Security benefits when you turn 65, you will be automatically enrolled in Medicare Part B, and you can choose to delay it if you have other health insurance coverage. However, you should check with the Social Security Administration to confirm your enrollment status.
What is the Part B premium for Medicare?
The standard Part B premium for Medicare is set annually by the Centers for Medicare & Medicaid Services. The amount can vary depending on your income and whether you are eligible for premium-free Medicare Part A.
Q: How can I sign up for Medicare Part B?
A: To sign up for Medicare Part B, you can contact your local Social Security office or the Social Security Administration. You can also enroll in Medicare Part B during the General Enrollment Period, which runs from January 1 to March 31 each year.
Q: What is the General Enrollment Period for Medicare Part B?
A: The General Enrollment Period for Medicare Part B is from January 1 to March 31 each year. If you enroll in Part B during this period, your coverage will start on July 1 of the same year.
Can I qualify for premium-free Medicare Part B?
You may qualify for premium-free Medicare Part B if you are eligible for premium-free Part A and have limited income and resources. The Social Security Administration can provide information on eligibility requirements.
What is the Part B late enrollment penalty?
If you do not sign up for Medicare Part B when you are first eligible and do not have other creditable coverage, you may have to pay a late enrollment penalty for as long as you have Part B coverage. The penalty is added to your Part B premium each month.
What is the Medicare Advantage Plan?
A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans.