2010 Medicare Part B Premium Cost and Coverage

Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)

• $135.00 per year. (Note: You pay 20% of the Medicare-approved amount for services after you meet the $135.00 deductible.)

Part B of Medicare is intended to fill some of the gaps in medical insurance coverage left under Medicare Part A. After the beneficiary meets the annual deductible, Medicare Part B will pay 80% of the "reasonable charge" for covered services, the reimbursement rate determined by Medicare; the beneficiary is responsible for the remaining 20% as "co-insurance".

Preventive Shots

Flu shots are covered one time per year during flu season. Three hepatitis B shots are covered if you are at medium or high risk.

The following is a list of items and services which can be covered under Medicare Part B:

1. Physicians' services;
2. Home Health Care;
3. Services and supplies, including drugs and biologicals which cannot be self-administered, furnished incidental to physicians' services;
4. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests;
5. X-ray therapy, radium therapy and radioactive isotope therapy;
6. Surgical dressings, and splints, casts and other devices used for fractures and dislocations;
7. Durable medical equipment;
8. Prosthetic devices;
9. Braces, trusses, artificial limbs and eyes;
10. Ambulance services;
11. Some outpatient and ambulatory surgical services;
12. Some outpatient hospital services;
13. Some physical therapy services;
14. Some occupational therapy;
15. Some outpatient speech therapy;
16. Comprehensive outpatient rehabilitation facility services;
17. Rural health clinic services;
18. Institutional and home dialysis services, supplies and equipment;
19. Ambulatory surgical center services;
20. Antigens and blood clotting factors;
21. Qualified psychologist services;
22. Therapeutic shoes for patients with severe diabetic foot disease;
23. Influenza, Pneumococcal, and Hepatitis B vaccine;
24. Some mammography screening;
25. Some pap smear screening, breast exams, and pelvic exams;
26. Some other preventive services including colorectal cancer screening, Diabetes training tests, bone mass measurements, and prostate cancer screening.

Medicare Part B is fairly comprehensive but far from complete.There are certain items and services which are excluded from coverage. Excluded services include:

1. Services which are not reasonable or necessary;
2. Custodial care;
3. Personal comfort items and services;
4. Care which does not meaningfully contribute to the treatment of illness, injury, or a malformed body member;
5. Prescription drugs which do not require administration by a physician;
6. Routine physical checkups;
7. Eyeglasses or contact lenses in most cases
8. Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses;
9. Hearing aids and examinations for hearing aids.
10. Immunizations except for influenza, pneumococcal and hepatitis B vaccine;
11. Cosmetic surgery;
12. Most dental services.
13. Routine foot care

Medicare Part B Premium, Deductible and Co-pays

Medicare Part B is optional and is financed largely by monthly premiums paid by individuals enrolled in the program. Participants may have this premium automatically deducted from their Social Security check. Since 2007, for the first time in the history of the Medicare program, the premium has been income based.

Medicare Part B has an annual deductible requirement, as well. Each year, before Medicare pays anything, the patient must incur medical expenses equal to the deductible, based on Medicare's approved "reasonable charge," not on the provider's actual charge.

As described above, a major problem with Medicare Part B is the difference between the cost of medical items or services, particularly physicians' services, and the Medicare approved "reasonable charge."

When a physician accepts "assignment", he or she agrees to accept the Medicare approved amount as full payment. Medicare will pay 80% and the patient will pay the 20% co-payment. When a physician does not accept assignment the patient is liable for the co-payment plus a balance above the Medicare fee schedule amount.

However, under federal law there is a set limit as to the amount a physician may balance bill. A physician may balance bill only 115% of the Medicare fee schedule amount. For example, assume that you go to a doctor who does not accept assignment; his actual charge may be $100, but the Medicare fee schedule is only $70. The doctor may only bill you 115% of the fee schedule amount or $80.50. If the doctor bills above $80.50 he is violating federal law.