Medicare Part B

Eligibility and Enrollment

As with Medicare Part A, you automatically get Medicare Part B after you have had Social Security Disability Insurance (SSDI) benefits or Childhood Disability Benefits (CDB) for 24 months.

Around the 20th month of getting an SSDI or CDB benefit, you should get a notice in the mail telling you that your Medicare benefits are going to start soon. See the DB101 section on Part A for more details on enrollment.

One of the big differences between Parts A and B is that you generally have to pay a premium for Part B. With this in mind, you don’t have to keep Part B.

When you get your notice about Medicare benefits, there will be information on how to decline Part B. Keep in mind that you may be eligible for programs that help pay the Part B premium and that if you decline Part B coverage when it’s first available, you may have to pay higher premiums when you do sign up.

The Part B premium is generally taken out of your SSDI check. In 2017 the premium is $109.00. If your income is over $85,000, your premium will be higher.

Special premium rules for 2017

For 2016, there are special rules about the Medicare Part B premium:

  • For most people who have to pay a premium, the amount will be $109.00 per month.
  • However, some people will have to pay a $134 premium in 2017, including:
    • People who enroll for the first time, and
    • People who don’t get Social Security benefits.

Get more information about Medicare premiums in 2017.

The Benefit

Medicare Part B helps pay for medical care when you’re not in the hospital. Under certain circumstances, it will help pay for:

  • Outpatient care: Doctor and practitioner services; Emergency Room services; Outpatient Hospital services; Medical and surgical services and supplies; Mental health care, rural health clinic and federally qualified health center services, Urgent care.
  • Home Health Care
  • Screening exams: Abdominal aortic aneurysm; Bone mass measurement; Cardiovascular; Colorectal; Diabetes; Glaucoma; One physical for new Medicare enrollees; Mammograms; Pap tests; Prostate exams.
  • Procedures and Tests: Blood transfusions; Clinical laboratory tests; Other diagnostic tests like X-rays, MRIs, CTs, EKGs, etc.
  • Supplies and Equipment: Diabetes supplies; Durable medical equipment for use in the home; Kidney dialysis equipment; Prosthetics and orthotics.
  • Rehabilitation: Occupational, speech, and physical therapy.
  • Immunizations: Flu; Hepatitis B; Pneumococcal.
  • Some services only in very specific situations: Chiropractic; Eye exams; Eyeglasses for specific medical conditions; Diabetes self-management, Foot exams and foot treatment for diabetes; Hearing and balance exams; Injectable cancer or immunosuppressive drugs; Health care in Canada under rare circumstances.
  • Other services: Ambulance transport; Ambulatory Surgery Center fees; Clinical research studies; Medical nutrition therapy; Second surgical opinions; Smoking cessation; Surgical dressing services; Telemedicine; Transplant care.

What Medicare Part B Will Pay For

For the most part, Medicare Part B will only help pay for the above services in certain situations. Medicare’s general rule is that it will only pay for things that it finds medically necessary.

Medicare’s general rule is that it will only pay for things that it finds medically necessary.Part B may only pay for some things if you have certain risk factors, or it might only help pay for a certain number of things in a given time period (like once every five years, for example). Other services are offered every year.

The equipment and supplies must be bought through a certified Medicare supplier.

Some services are only covered in very specific situations. For example, Medicare Part B will pay for eyeglasses only if you need them after a specific type of cataract surgery.

How Much Medicare Part B Will Pay

In addition to the monthly Part B premium, you may have to pay other costs for the services described above. Medicare has rules about how much it will pay for each of the Part B services.

Medicare will pay the entire costs of some services, like flu shots.

For other services, like mental health, Medicare will pay for 80% of the cost.

For most services, Medicare will pay for 80% while you pay the remaining 20% . This is called coinsurance.

For most Part B services, Medicare will help pay only after you’ve spent a certain amount of money for the year on medical services. This is the yearly deductible, and it’s $183 in 2017.

Example

Medicare may help pay for occupational therapy to help you return to daily living activities.

Let’s say that you haven’t received any medical services for the year and your doctor prescribes occupational therapy at a cost of $283 .

Since you haven’t paid your deductible yet, you would have to pay the first $183.

After that, there’s still $100 left to pay ($283 cost - $183 deductible = $100). And since coinsurance applies, Medicare would pay for 80% of the remaining $100. So Medicare would pay $80 and you’d pay another $20.

Let’s say later in that same year, you are having balance problems and your doctor decides you need a balance exam. This is also covered by Medicare. But since you have already paid your $183 deductible for the year, you would only need to pay coinsurance for this exam.

Medicare and You has an excellent list that tells you when Medicare will pay for the above services and the percentages of each service that it will pay for.

The above description describes the Part B benefit under Original Medicare. Some of the coinsurance, deductible, and copayment costs might be paid for by a Medigap policy, a Medicare Savings Program, Medi-Cal, or an employer's plan.

Help Paying for Part B Premiums and Costs: Medicare Savings Programs

There are three Medicare Savings Programs that can help pay for Part B costs:

Qualified Medicare Beneficiary (QMB)

The Qualified Medicare Beneficiary (QMB) program pays for Medicare Part A and Part B premiums, coinsurance, copayments, and deductibles. To qualify, you must:

  • Be eligible for or enrolled in Medicare Parts A and B;
  • Have countable income at or below 100% of the Federal Poverty Guidelines (FPG) ($1,005 per month, $1,353 for couples);
  • Have resources at or below the limit ($7,390 for individuals, $11,090 for couples); and
  • Meet all other Medi-Cal eligibility requirements.

This program does not apply benefits retroactively, which means that you can’t get help paying for costs for past months.

Specified Low-Income Medicare Beneficiary (SLMB)

The SLMB program pays for Medicare Part B premiums. To qualify, you must:

  • Be eligible for Medicare Parts A and B;
  • Have countable income at or below 120% of FPG ($1,206 per month, $1,624 for couples);
  • Have resources at or below the limit ($7,390 for individuals, $11,090 for couples), and
  • Meet all other Medi-Cal eligibility requirements

The SLMB benefit can help pay for costs that you had starting three months before the month you applied.

Qualified Individual (QI)

The QI program pays for Medicare Part B premiums. To qualify, you must:

  • Be eligible for Medicare Parts A and B;
  • Have countable income at or below 135% of FPG ($1,357 per month, $1,827 for couples);
  • Have resources at or below the limit ($7,390 for individuals, $11,090 for couples); and
  • Meet all other Medi-Cal eligibility requirements.

The QI benefit can help pay for costs that you had starting three months before the month you applied. There are only a limited number of QI slots available each year, and they are filled on a first come, first served basis.

For Medicare Savings Programs, it’s important to know that not all of your income counts. The same is true for your assets. For example, the home you live in and the car you drive to work don’t count as assets.

Call your county Health Insurance Counseling & Advocacy Program (HICAP) office to learn more about whether you qualify for a Medicare Savings Program. If you do, they'll explain how to apply at your local county social services agency.

Other Help from Medi-Cal

If you’re not in a Medicare Savings Program, Medi-Cal may pay for some of your Medicare Part B costs. Medi-Cal will pay your Part B premiums if:

  1. You have Medi-Cal with no share of cost. This includes people who receive Supplemental Security Income (SSI), or who are in the Working Disabled Medi-Cal program; or
  2. You have a Medi-Cal share of cost of $500 or less; or
  3. You meet your Medi-Cal share of cost in a month; or
  4. You are in long-term care and are certified as Medi-Cal eligible on the first of each month.

For people with a Medi-Cal share of cost over $500, the rules about how Medi-Cal helps with Part B premiums changed in November 2008. For months when you meet your share of cost, Medi-Cal will pay your Part B premiums. For months when you don’t meet your share of cost, Medi-Cal will not pay your Part B premiums.

Declining Part B Coverage

You can decline Medicare Part B coverage if you can’t get another program to pay for it and you don’t want to pay for it yourself.

The important thing to know about declining Part B coverage is that if you decline it and then decide that you want it later, you may have to pay a higher premium. Whether or not you will have to pay this penalty depends on whether or not you have other health insurance when you decline Part B coverage. If you don’t have other insurance, you’ll have to pay an additional 10% on your premium for every full year that you decline Part B coverage. In 2017, the Medicare Part B premium is $109.00 per month (or higher if your annual income is over $85,000).

If you decline Part B coverage when it’s first offered, you can only sign up during certain times:

  • You can sign up between January 1 and March 31 of each year, which is known as the General Enrollment Period. Your Medicare Part B coverage will not begin until July 1 of that year. Again, you will have to pay a higher premium in some cases.
  • If you originally declined Part B because you had group health coverage through a job or spouse’s job, you can sign up for Part B when you lose that coverage. You have 8 months starting in the month when the job ends (or from when you lose your coverage – whichever comes first). If you sign up in those 8 months, you won’t have to pay a penalty.