With thousands of Americans turning 65 every day, Medicare plans are in the news, on commercials, and on people’s minds more than ever before. To make the best choices for coverage, it’s important to have a solid understanding of the program, starting with Original Medicare.
In this guide to understanding Medicare Part B, we’ll cover some Medicare frequently asked questions and details about the medical services aspect of Original Medicare, including:
Medicare Part B is the part of Original Medicare that covers outpatient medical care. Medicare Part B covers outpatient services from doctors and other health care providers, home health care, durable medical equipment, and some preventive services.
In other words, you can think of Medicare Part B as Medicare medical insurance that doesn’t require an inpatient hospital stay. (Hospital coverage falls under Medicare Part A.)
Part B is a part of Original Medicare (along with Part A), but you can also choose to receive your Medicare Part B benefits as part of a Medicare Advantage plan.
If you go this route, rest assured that Medicare Advantage plans are required to cover everything that Medicare Part B covers, so you won’t be missing out on any benefits if you choose to use this private health insurance option.
Medicare Part B offers comprehensive coverage that is broken down into 2 categories:
You will be covered under Part B when you use these services:
Medicare Part B generally only covers medications that you’d receive at a doctor’s office. Meanwhile, prescription drugs that you fill at a pharmacy are covered under Medicare Prescription Drug Plans.
Medicare Part B offers minimal coverage for dental, vision and hearing services.
Part B covers medically-necessary procedures like glaucoma screening, but doesn’t cover routine vision, hearing, or dental services.
However, many Medicare Advantage plans do offer coverage for routine vision, hearing, and dental care.
There are 2 different types of costs associated with Medicare Part B:
When you enroll in Medicare Part B, you will have to pay a monthly premium. For 2021, the base premium is $148.50. The premium might have been higher, but it was capped by Congress due to the 2021 changes to Medicare.
You will also have to pay out-of-pocket costs when you use your Medicare Part B benefits. You can expect to pay these costs out of pocket:
It’s important to note that unlike private health insurance, your costs are not capped under Original Medicare Part B. For this reason, many people choose to add Medigap coverage, or switch from Original Medicare to a Medicare Advantage plan. And you must continue to pay the Part B premium even if you choose to enroll in a Medicare Advantage plan.
If you receive retirement income from Social Security or the Railroad Retirement Board, your Medicare Part B premium will be automatically deducted from your checks.
Higher earners may also have an additional charge added to their Part B premiums. The extra amount, known as IRMAA (Income Related Monthly Adjustment Amount), kicks in for single taxpayers with incomes over $88,000 and joint filers with incomes over $176,000.
There are six income levels of IRMAA. As an example, if you are a single filer with an income of $90,000, your total Medicare Part B premium for 2021 would be $207.90. Of this amount, the base premium is $148.50 and the IRMAA amount is $59.40.
Click here to see a full list of all IRMAA amounts for 2021.
Medicare is designed to be as affordable as possible, but the premiums may be challenging to those on smaller, fixed incomes.
Medicare Savings Programs can help qualifying Medicare beneficiaries with the costs of their premiums. Beneficiaires may also qualify for assistance with Medicare Part B deductibles and coinsurance amounts.
To qualify for one of the Medicare Savings Programs, you must meet certain income and asset limits. Generally speaking, if you qualify for Medicaid, you will qualify for Medicare Savings Programs. Depending on your level of Medicaid benefits, you might not have to pay any part of the Medicare Part B premium.
You must apply for Medicaid and the Medicare Savings Programs through your home state.
Anyone who qualifies for premium-free Part A is automatically eligible for Medicare Part B. If you must pay a premium for Medicare Part A, then your Medicare Part B eligibility depends on whether you’re a U.S. citizen, or a permanent legal resident for five or more continuous years.
If you meet the citizenship or residency requirement, you will become eligible to enter Medicare Part B when one of these applies:
Medicare Part B is a voluntary program, which requires paying a monthly premium. Generally speaking, you don’t need to apply for Part B if you have health insurance through your (or your spouse’s) current employer.
For example, if you or your spouse are still working past age 65 and have an employer or union health plan, you can delay Part B enrollment. We’ll talk more about this later.
If you don’t have health insurance that Medicare considers as creditable coverage, you should enroll in Part B when you’re first eligible to avoid a late enrollment penalty.
Depending on your circumstances, you may be automatically enrolled into Medicare Part B, or you may need to sign up.
If you have to sign up manually, you can do so online on the Social Security Administration’s (SSA) website or in person at your local Social Security office. You can also apply for Social Security Medicare Part B benefits by phone, or fax an application to the SSA.
But if you sign up manually, you must be sure to enroll during a valid Medicare Part B enrollment period. There are 3 enrollment windows for Part B:
If you’re turning 65 and aging into Medicare: You will automatically receive Part B coverage only if you’re already receiving benefits from Social Security or the Railroad Retirement Board at least four months before your 65th birthday.
If you qualify for Part B before age 65: You’ll be automatically enrolled if you receive Social Security or Railroad Retirement Board disability benefits for 24 consecutive months. Your Medicare Part B coverage will begin on the first day of the 25th month you receive disability payments.
If you’re automatically enrolled, you can expect to receive your Medicare Part B card up to three months before your 65th birthday or your 25th month of disability benefits.
Note: ALS patients of any age will enter Part B on the first day they receive Social Security Disability Income. But if you live in Puerto Rico, or if you have ESRD, your enrollment is not automatic. You will need to apply for Medicare Part B manually.
Yes, you can qualify for Medicare Part B based on an ESRD diagnosis. However, your enrollment isn’t automatic, so you’ll need to apply for coverage.
The eligibility requirements for ESRD can be complicated and change based on whether or not you receive a kidney transplant.
However, most people will begin Medicare Part B coverage after receiving dialysis for 4 consecutive months at a dialysis treatment facility, or as early as the first month of starting dialysis at home.
When enrolling in Medicare Part B with ESRD, it’s important to keep in mind that you’ll get more complete coverage if you also enroll in Part A.
Note: Beginning January 1, 2021, Medicare beneficiaries with ESRD will be able to get coverage through Medicare Advantage plans as outlined in our 2021 changes to Medicare article.
Although most people receive Part A coverage without paying a premium, you will have to pay a monthly premium when you begin Part B, so you’ll want to make sure you really need Part B coverage before you enroll.
As mentioned earlier, most people should enroll in Medicare Part B when they first become eligible. However, if you’re still working and have qualifying health insurance, you may choose to delay taking Part B.
Retired military members who have TRICARE coverage and Medicare Part A must also have Part B to remain eligible for TRICARE.
If you don’t need Medicare Part B coverage when you become eligible, you can delay enrollment. This way, you won’t pay a premium for coverage you don’t need.
You can consider delaying Medicare Part B when:
It’s very important to enroll in Medicare Part B when you’re first eligible, or make certain that your employer coverage meets Medicare’s requirements for coverage. If you enroll late, or if your employer coverage isn’t adequate, you may have to pay the Medicare Part B penalty .
Late enrollment penalties are added to your base Medicare Part B premium (more details below). And you will pay the penalty as long as you’re enrolled in Medicare Part B, which is probably for the rest of your life.
Note: The Medicare Part B late enrollment penalty is 10% for each12-month period that you went without coverage. This amount can add up over the years, which is why it’s so important to enroll when you’re first eligible.
If you delay taking Medicare Part B because you’re still working or covered by your spouse’s employer or union plan, you’ll receive a Special Enrollment Period when your employer coverage ends.
Typically, you’ll be eligible for an 8-month enrollment window, which begins the earlier of:
During this 8-month window, you can enroll in Medicare Part B and a private plan like Medicare Advantage or Medicare Supplement insurance, if you choose to.
Due to the out-of-pocket costs you’re responsible for under Medicare Part A and B, you may choose to purchase private insurance coverage that enhances your Original Medicare benefits.
Medicare Supplement insurance, also known as Medigap, covers some or all of the out-of-pocket expenses that you would normally have to pay.
You get a one-time Medigap Open Enrollment Period which lasts for 6 months and begins as soon as both of these are true:
Since your open enrollment window doesn’t start until you actually enroll in Medicare Part B, you’ll still have the right to buy Medicare Supplement insurance even if you delay taking Part B past age 65.
The benefit of enrolling in Medigap during your open enrollment period is that your application can’t be denied and you can’t be charged more because of a health condition.
If you want to get Medigap after your 6-month open enrollment period, you will probably have to go through medical underwriting. If this is the case, your coverage can be declined, or you might be charged a higher premium for pre-existing conditions.
When you have Medigap, Original Medicare is your primary coverage, and your Medigap policy supplements it. You will show both your Original Medicare card and your Medigap card when you receive Medicare-covered services.
As you approach Medicare Part B eligibility, consider these 3 tips before your Medicare Part B enrollment:
If you decide to keep Medicare Part B or apply if you’re not automatically enrolled, consider if you want to supplement your coverage. Most people choose to add one or more of these options to their Original Medicare coverage:
Other people choose to get their Original Medicare (Parts A and B) through Medicare Advantage (Medicare Part C). These plans combine Medicare Parts A and B, and most include prescription drug coverage. If you enroll in Medicare Advantage, you can’t have a Medigap policy at the same time.
To make a sound decision, be sure to consider your budget and healthcare needs while making sure your doctor accepts any potential plan. You’ll also want to ensure that your medications are covered by the plan.
For more help with understanding Medicare Part B or finding private Medicare plan options in your area, call 800-620-4519 to speak to a licensed insurance agent. You can also find Medicare Advantage plans or compare Medicare Part D plans online through our plan comparison tool.
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