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:
What Is Medicare Part B?
What Benefits Are Covered Under Medicare Part B?
Who Is Eligible For Medicare Part B?
Do I Have to Apply for Medicare Part B?
How Do I Sign Up for Medicare Part B?
Who Gets Medicare Part B Automatically?
Can I get Part B If I Have Kidney Failure (ESRD)?
I Have Medicare Part A – Do I Need To Get Medicare Part B?
Delaying Part B Enrollment
Medicare Part B And Medigap
How Much Does Medicare Part B Cost?
How To Get Help With Part B Premiums
What Is Medicare Part B?
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.
What Does Medicare Part B Cover?
Medicare Part B offers comprehensive coverage that is broken down into 2 categories:
Medically necessary services, which are intended to diagnose or treat a medical condition.
Preventive services, which prevent or detect illnesses at an early stage.
You will be covered under Part B when you use these services:
Doctor’s visits, including specialists
Physical and occupational therapy
Mental health coverage
Durable medical devices (DME)
Infusion-based cancer treatments, like chemotherapy
Limited prescription drugs and certain vaccines
Outpatient hospital services, including same-day surgeries
Although most vaccines are covered by Medicare Part D, Medicare Part B will cover the COVID-19 vaccine. Medicare Part B also covers the flu, hepatitis B, and pneumococcal vaccines.
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.
Does Medicare Part B Cover Dental, Vision, And Hearing?
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.
How Much Does Medicare Part B Cost?
There are 2 different types of costs associated with Medicare Part B:
Premiums you pay to have coverage, and
Costs you pay out of pocket when you receive covered services and procedures.
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:
Medicare Part B deductible: $203 for 2021.
Medicare Part B coinsurance: 20% of the Medicare-approved charge for every covered service or procedure.
Medicare Part B excess charges: Up to 15% of the Medicare-approved charge for services and procedures administered by providers who don’t accept Medicare-approved prices.
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.
Cost of Medicare Part B for Higher Earners
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.
How To Get Help With Medicare Part B Premiums
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.
Medicare Part B Eligibility Requirements
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:
You turn 65 years old,
You receive Social Security Disability Income for 24 consecutive months, regardless of age, or
You’re diagnosed with either End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig’s disease), regardless of age.
Do I Have to Apply for Medicare Part B?
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.
How Do I Sign Up For Medicare Part B?
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:
Medicare Part B Initial Enrollment Period (IEP): A 7-month period that begins 3 months before you turn age 65 (or meet the eligibility requirements) and ends 3 months after you meet the eligibility requirements.
Medicare Part B General Enrollment Period (GEP): An enrollment window that runs from January 1 to March 31 of each year. The GEP is for people who have missed their initial enrollment period and don’t qualify for a Special Election Period.
Medicare Special Election Periods (SEPs): Only available in special circumstances. The most common SEP is for those who work past age 65 and delay taking Medicare Part B. In this case, you would be eligible for a Medicare Part B Special Enrollment Period when your employer or union health insurance coverage ends.
Who Automatically Gets Medicare 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.
Can I Get Medicare Part B If I Have Kidney Failure (ESRD)?
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.
Do I Need To Get Medicare Part B If I Have Medicare Part A?
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.
Delaying Medicare Part B Enrollment
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:
You are still working for an employer with more than 20 employees, and your drug and medical coverage meet certain Medicare requirements, or
You’re covered by a spouse’s employer or union plan that meets the same criteria.
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.
Medicare Part B Special Enrollment Period If You’re Still Working After Age 65
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:
Your last day of employment, or
The last day of your employer coverage.
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.
How Medicare Part B Works With Medigap Plans
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:
You are at least 65 years old, and
You are enrolled in Medicare Part B.
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.
Understanding Medicare Part B Conclusion
As you approach Medicare Part B eligibility, consider these 3 tips before your Medicare Part B enrollment:
Know if you’re going to work beyond age 65. If you’ll have qualifying coverage from your employer or union, then you’ll want to delay taking Part B to avoid paying premiums.
If you’re automatically enrolled in Part B and don’t yet need it, you’ll have to contact Social Security to cancel your Medicare coverage. You will be asked to return your Medicare card.
Since you can be subject to late enrollment penalties, don’t delay taking Part B just because of the cost.
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:
Medicare Supplement Insurance (Medigap): You must have both Part A and B through the Original Medicare program.
Medicare Part D (Prescription Drug Plans): You can add separate Part D drug coverage to Original Medicare Part A and/or Part B.
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.