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Medicare Part B: the Basics

Updated: Sep 21, 2023

By Martine G. Brousse

"The Medical Bill Whisperer... and insurance stuff too"

Patient Advocate, Certified Mediator

AdvimedPro


September 11, 2023


Watch the YouTube video: https://youtu.be/6iri0AdL5wQ


Medicare has many parts.: A,B,C,D

This blog addresses part B, a second blog in a serie of 4


First, those of you with a Medicare Advantage plan, be aware that although your plan must offer the same services, special coverage guidelines may apply.


In blog on part A, I covered services considered “in patient’ or “facility”. This means hospital, skilled nursing facility, hospice and usually meaning that the patient is incapacitated and in an institution.


A. What Part B covers:

1. Part B covers mostly what are considered “Professional” services, meaning those of individuals.

· These individuals may be treating you in a hospital but are not its employees.

· These are the PCPs, specialists, therapists, mental health clinicians, Nurse Practitioners, Physician Assistants, and other professionals with some form of a medical license.

· Part B covers their services whether in a facility, in an office, or at home through teledoc.


2. Outpatient services:

· Services rendered in an ER, urgent care clinic or surgicenter are also Part B.

· "Observation" days in a hospital are also considered Outpatient. This is often a cause of confusion, as Observation can last up to 3 days, while your Dr decides whether you should be admitted or discharged. If you are admitted, Part A takes over.


3. Other various services:

· Ambulance (ground)

· Labs

· Durable medical equipment (home infusions, walker, CPAP machine etc)

· Tests and Imaging (MRIs, X-rays, etc)

· Preventive care (well visit, vaccinations)

· Some home health services (if confined at home and unable to get to the treatment or therapy to help improve or maintain your condition)


B. Your cost


1. “Allowance”

· Payment to a provider, and ultimate liability to you, is based on an “allowance”, or fee calculated to be the fair market value of a medical service or item

· After you meet the yearly deductible ($ 226.00 in 2023), part B pays 80% of the allowance

· The 20% remaining balance is your “co-pay”

· Part B covers 100% for labs and preventive care


C. The role of the “Supplemental” insurance


· Most Medicare patients have a secondary (also called medigap or supplemental) insurance to cover part or all of their financial liabilities.

· Depending on the level of coverage, that policy may cover part or all of your copays and even the deductible

· Low-income seniors may qualify for Medicaid as that secondary plan. They are then called “medi-medi” or "dual eligible” patients.

· Medicare will sends its claims directly to the secondary as a courtesy, but you must accept when you first apply for coverage.


D. Exceptions and Limitations


1. Medi-Medi patients:

· The secondary coverage only applies – and pays – if the medical provider is contracted with or accepts Medicaid. This is a very limited number of individuals, unfortunately.

· If they are not contracted, they can legally bill the patient for the 20% copay and/or deductible

· The patient can show proof of “financial hardship” and ask for a courtesy or hardship wrote off, however Medicare deductibles must usually be paid by the patient.


2. Supplemental insurance rules:

· Be timely as penalties will apply if you do not pick a supplemental plan within the open enrollment period

· That enrollment period starts 6 months before the month you turn 65 and get Medicare coverage.

· While all plans in the country are standardized (Plan A or F for example, offer the exact same level of coverage whether in CA or TX), they are administered by private commercial companies (Aetna, HealthNet, Humana, AARP, Cigna etc). Each company only operates in certain areas. So your Humana plan F in AK may be the same as the one administered by BCBS in AZ yet not under the same insurance name.

· Coverage and prices vary by plan and area, and your agent or Medicare navigator can help you choose the best one.



E. Tips:


1. Unlike Part A, the Part B deductible is only applied once a year


2. Medicare.gov is a treasure of info, simple and clearly searchable. The tab “what Medicare covers” is especially easy to use to find coverage and pricing data. Comparing supplemental plans in your area, what they cover and at what price is also easy to do on the website.


3. Providers must be contracted with Medicare and/or accept Medicare Assignment. If not, you must be informed in writing, and sign whether you decide to go ahead as your cost will be much greater than the 20% copay. Go here to find one.



Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.


the basics of Medicare part B
the basics of Medicare part B

(424) 999 4705 - F (424) 226 1330

@martine brousse 2023

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