Medicare Part B

Introduction

Outpatient or supplementary medical insurance.

Covers:

• physicians
• nurse practitioners
• social workers
• psychologists
• therapists
• laboratory tests
• durable medical equipment
• home visits (traditional fee-for-service)

Does not cover:

• health maintenance physical examinations
• dental care
• hearing aids
• eye glasses
• foot care
  • orthopedic shoes
• cosmetic surgery
• care in foreign countries
• long-term care
• round the clock home care
• home maker services
• help with activities of daily living

Eligibility:

• entitlement to Medicare Part A or citizen or permanent resident of USA
• must enroll & pay premiums ($96-$354/month in 2010) depending upon income
• generally premiums deducted from social security check

A deductable ($166/year 2016) is applied to reimbursement for outpatient services. After deductable is paid, Medicare part B covers 80% of office visits & 100% of diagnostic labs.

Durable equipment including pressure-relieving mattresses are covered when indicated

Medicare policy indicates that home health agencies should teach patients & their families to assume responsibilities for their own care, rather than rely on the home health agency for provision of all aspects of care

Part B is financed in 2 ways.

• monthly premiums ($105-390/month in 2016) deducted from Social Security benefits of enrollees
  • premiums cover 25% of average expenditures for aged beneficiaries
• contributions from the general revenue of the US Treasury

Physicians must choose among 3 options in relation to the Medicare fee-for-service: participant, a nonparticipant, or a private contractor.

Participants submit a claim to the Part B carrier for each Medicare-covered service, accepts Medicare fee for the service (80% of its preestablished amount) & bills the patient of patient's other insurance for no more than 20%

Nonparticipants can bill patients directly for up to 15% more than 95% of Medicare allowed amounts; the patient pays the physician, then submits a claim to Medicare for partial reimbursement (80% of 95% of the allowed amount); Medicare reimburses the patient, not the provider

Physicians may opt out of Medicare entirely, but must do so for all of their patients (concierge practice); they enter into private contracts with their patients

More general terms

• Medicare