Your Part B coverage is a little more then standard doctor coverage, but typically covers 2 types of services. Those that are medically necessary. Meaning services and supplies needed to diagnose or that a medical condition that meet accepted standards of medical practice. And preventative services. meaning services that prevent illness (like the flu) or to detect it at an early stage, when treatment is most likely to work best.
You will pay nothing for most preventative services if you get the services from a healthcare provider that accepts assignment.
Part B covers:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Mental health (outpatient and certain partial hospitalization)
- Getting second opinions before surgery
- limited outpatient drugs
Medicare covers clinical research studies, which test different types of medical care, like how well a cancer drug works. These studies help doctors and researchers see if a new treatment works and it's safe. Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover some costs, like office visits and tests, and in certain qualifying clinical research studies.
All people with Part A and/or Part B are covered, in qualifying studies.
Your costs in Original Medicare
You may pay 20% of the Medicare-approved amount, depending on the treatment you get. The Part B deductible may apply.
Medicare will help pay for some of your costs if you join a covered clinical research study.
Medicare pays routine costs for items and services, including:
- Room and board for a hospital stay that Medicare would pay for even if you weren't in a covered research study.
- An operation to implant an item that’s being tested.
- Treatment of side effects and complications that may result from the study.
Medicare won't pay for:
- The new item or service the study is testing (except for certain medical devices) unless Medicare would cover the item or service even if you weren't in a study.
- Items and services the study gives for free. Many times the study sponsor will give the treatment for free.
- Items or services given only to collect data and not used in your direct health care, like monthly CT scans for a condition that usually requires only a yearly scan.
- Coinsurance and deductibles.
Medicare Part B (Medical Insurance) covers ambulance services to or from a hospital, critical access hospital (CAH), or skilled nursing facility (SNF). Medicare covers and helps pay for ambulance services only when other transportation could endanger your health, like if you have a health condition that requires this type of transportation.
Medicare will only cover ambulance services to the nearest appropriate medical facility that’s able to give you the care you need. If you choose to be transported to a facility farther away, Medicare’s payment will be based on the charge to the closest appropriate facility. If no local facilities are able to give you the care you need, Medicare will pay for transportation to the nearest facility outside your local area that’s able to give you necessary care.
Emergency ambulance transportation
You can get emergency ambulance transportation when you’ve had a sudden medical emergency, and your health is in serious danger because you can’t be safely transported by other means, like by car or taxi.
These are some examples of when Medicare might cover emergency ambulance transportation:
- You're in shock, unconscious, or bleeding heavily.
- You need skilled medical treatment during transportation.
Remember, these are only examples. Medicare coverage depends on the seriousness of your medical condition and whether you could’ve been safely transported by other means.
Medicare may pay for emergency ambulance transportation in an airplane or helicopter if your health condition requires immediate and rapid ambulance transportation that ground transportation can’t provide, and one of these applies:
- Your pickup location can't be easily reached by ground transportation.
- Long distances or other obstacles, like heavy traffic, could stop you from getting care quickly if you traveled by ground ambulance.
Non-emergency ambulance transportation
You may be able to get non-emergency ambulance transportation if you have a written order from your doctor saying that ambulance transportation is medically necessary.
Durable medical equipment
Medicare Part B (Medical Insurance) covers medically necessary durable medical equipment (DME) that your doctor prescribes for use in your home. Only your doctor can prescribe medical equipment for you. DME meets these criteria:
- Durable (can withstand repeated use)
- Used for a medical reason
- Not usually useful to someone who isn't sick or injured
- Used in your home
- Has an expected lifetime of at least 3 years
DME that Medicare covers includes, but isn't limited to:
- Air-fluidized beds and other support surfaces (these supplies are only rented)
- Blood sugar monitors
- Blood sugar (glucose) test strips
- Canes (except white canes for the blind)
- Commode chairs
- Continuous passive motion (CPM) machine
- Hospital beds
- Infusion pumps and supplies (when necessary to administer certain drugs)
- Manual wheelchairs and power mobility devices
- Nebulizers and nebulizer medications
- Oxygen equipment and accessories
- Patient lifts
- Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
- Suction pumps
- Traction equipment
If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment:
- You may need to rent the equipment.
- You may need to buy the equipment.
- You may be able to choose whether to rent or buy the equipment.
Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them.
It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment. If suppliers don't accept assignment, there’s no limit on the amount they can charge you.
Competitive Bidding Program
If you live in or visit certain areas, you may be affected by Medicare's Competitive Bidding Program. In most cases, Medicare will only help pay for these equipment and supplies if they're provided by contract suppliers when both of these apply:
- You have Original Medicare.
- You get competitively bid equipment and supplies in competitive bidding areas.
Contract suppliers can't charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.
Mental health outpatient
Medicare Part B (Medical Insurance) covers mental health services and visits with these types of health professionals:
- Psychiatrist or other doctor
- Clinical psychologist
- Clinical social worker
- Clinical nurse specialist
- Nurse practitioner
- Physician assistant
These visits are often called counseling or therapy. Medicare only covers the visits when they’re provided by a health care provider who accepts assignment.
Part B covers outpatient mental health services, including services that are usually provided outside a hospital, like in these settings:
- A doctor’s or other health care provider's office
- A hospital outpatient department
- A community mental health center
Part B also covers outpatient mental health services for treatment of inappropriate alcohol and drug use.
Part B helps pay for these covered outpatient services:
- One depression screening per year. The screening must be done in a primary care doctor’s office or primary care clinic that can provide follow-up treatment and referrals.
- Individual and group psychotherapy with doctors or certain other licensed professionals allowed by the state where you get the services.
- Family counseling, if the main purpose is to help with your treatment.
- Testing to find out if you’re getting the services you need and if your current treatment is helping you.
- Psychiatric evaluation.
- Medication management.
- Certain prescription drugs that aren’t usually “self administered”(drugs you would normally take on your own), like some injections.
- Diagnostic tests.
- Partial hospitalization.
- A one-time “Welcome to Medicare” preventive visit. This visit includes a review of your possible risk factors for depression.
- A yearly “Wellness” visit. Talk to your doctor or other health care provider about changes in your mental health. They can evaluate your changes year to year.
All people with Part B are covered.
Your costs in Original Medicare
- You pay nothing for your yearly depression screening if your doctor or health care provider accepts assignment.
- 20% of the Medicare-approved amount for visits to your doctor or other health care provider to diagnose or treat your condition. The Part B deductible applies.
- If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional copayment or coinsurance amount to the hospital.
Mental health - Partial hospitalization
Medicare Part B (Medical Insurance) covers partial hospitalization in some cases. Partial hospitalization provides a structured program of outpatient psychiatric services as an alternative to inpatient psychiatric care. It’s more intense than care you get in a doctor’s or therapist’s office. This treatment is provided during the day and doesn’t require an overnight stay. Medicare helps cover partial hospitalization services when they’re provided through a hospital outpatient department or community mental health center. Along with your partial hospitalization program, Medicare may cover these:
- Occupational therapy that’s part of your mental health treatment
- Individual patient training and education about your condition
Medicare only covers partial hospitalization if the doctor and the partial hospitalization program accept assignment.
Medicare doesn't cover:
- Transportation to or from mental health care services
- Support groups that bring people together to talk and socialize. (This is different from group psychotherapy, which is covered.)
- Testing or training for job skills that isn't part of your mental health treatment.
For Part B to cover a partial hospitalization program:
- You must meet certain requirements.
- Your doctor must certify that you would otherwise need inpatient treatment.
Your costs in Original Medicare
You pay a percentage of the Medicare-approved amount for each service you get from a doctor or certain other qualified mental health professionals if your health care professional accepts assignment. You also pay coinsurance for each day of partial hospitalization services provided in a hospital outpatient setting or community mental health center, and the Part B deductible applies.
Getting a 2nd opinion
A second opinion is when another doctor (in addition to your regular doctor) gives you his or her view about:
- Your health problem
- How to treat it
It can help you make a more informed decision about your care.
When your doctor says you have a health problem that needs surgery, you have the right to:
- Know and understand your treatment choices
- Have another doctor look at those choices with you (second opinion)
- Participate in treatment decisions by telling your doctor what you do and don't want
Find out when a second opinion is covered.
When to get a second opinion
- If your doctor says you need surgery to diagnose or treat a health problem that isn't an emergency. It's up to you to decide when and if you'll have surgery.
- If your doctor tells you that you should have certain kinds of major non-surgical procedures. Medicare doesn't pay for surgeries or procedures that aren't medically necessary, like cosmetic surgery. This means that Medicare won't pay for second opinions for surgeries or procedures that aren't medically necessary.
Finding a doctor for a second opinion
- Make sure the doctor giving the second opinion accepts Medicare. Find a doctor that accepts Medicare.
- Ask your doctor for the name of another doctor to see for a second opinion. Don't hesitate to ask—most doctors want you to get a second opinion.
- You can also ask another doctor you trust to recommend a doctor.
- Ask your local medical society for the names of doctors who treat your illness or injury. Your local library can help you find your local medical society.
What to do when you get a second opinion
Before you visit the second doctor, you may want to:
- Ask your doctor to send your medical records to the doctor giving the second opinion. That way, you may not have to repeat the tests you already had. Also, call the second doctor's office and make sure they got your records.
- Write down a list of questions to take with you to the appointment.
- Ask a friend or loved one to go to the appointment with you.
During the visit with the second doctor, you may want to:
- Tell the doctor what surgery you're considering.
- Tell the doctor what tests you already had.
- Ask the questions you have on your list. Encourage your friend or loved one to ask any questions that he or she may have.
What if the first & second opinions are different?
If the second doctor doesn't agree with the first, you may feel unsure what to do. In that case, you may want to:
- Talk more about your condition with your first doctor.
- Talk to a third doctor. Medicare helps pay for a third opinion.
Getting a second opinion doesn't mean you have to change doctors. You choose which doctor you want to do your surgery.
Limited outpatient drugs
Medicare Part B (Medical Insurance) generally doesn't cover most prescription drugs used at home. But, it does cover a limited number of outpatient prescription drugs under limited conditions. Generally, drugs covered under Part B are drugs you wouldn't usually give to yourself. These include drugs you get at a doctor's office or hospital outpatient setting.
Drugs that aren't covered under Part B may be covered under Medicare prescription drug coverage (Part D). If you have Part D, check your plan's formulary to see what outpatient drugs are covered.
Examples of drugs Part B covers: