What Does Medicare Part B Cover?
Think of Part B as your personal health toolkit. Every time you need to visit a doctor, receive medical tests or X-rays, or use outpatient services, Part B covers that.
For the most part, Medicare Part B coverage is all about preventive healthcare. Preventive healthcare helps you stay healthy with screenings, vaccinations, and positive lifestyle changes. This type of care has a vital impact on your overall, long-term health.
Essential vaccinations
Medicare Part B includes annual flu shots and other important vaccinations for staying healthy.
Screening for health conditions
Chronic illnesses and health conditions are best treated when you and your doctor notice them early. That’s why Part B includes screenings for diabetes, breast cancer, cardiovascular disease, and more.
Your annual checkup
Part B covers yearly visits to the doctor, which help ensure you are on track to good health as part of a complete preventive program.
Healthy lifestyle changes
Part B also helps you make lifestyle changes to improve your health. For example, if you need help to stop smoking or lose weight, Part B covers smoking cessation programs and medically approved weight loss programs.
What Does Medicare Part B Not Cover?
While Medicare Part B covers a great deal, here are a few examples of what it doesn’t cover:
- Routine dental, hearing, and vision care
- Medical services outside the U.S.
- Alternative medicines
What Is The Difference Between Medicare Part A And Part B?
Medicare Part A primarily covers inpatient care including hospitalization costs. Medicare Part B covers outpatient care such as preventive medicine and doctor visits.
Differences between Medicare Part A and Part B
When Are You Eligible For Medicare Part B?
In general, Medicare eligibility requires that you be 65 or older and a U.S. citizen or legal U.S. resident for at least five continuous years to qualify. You may also apply for Medicare if you are younger than 65 and have certain disabilities. If you currently have Part A coverage, you are also eligible for Part B.
When To Sign Up For Medicare Part B
Medicare Part A and Part B enrollment is automatic if you’re already collecting Social Security. If you’re not collecting and meet the age requirement, you can apply for Medicare through Social Security during your Initial Enrollment Period, which is:
- Three months before your 65th birthday month
- Your 65th birthday month
- Three months after your 65th birthday month
How To Sign Up For Medicare Part B
To sign up for Medicare Part B, you can visit SocialSecurity.gov, call Social Security at 1-800-772-1213 (TTY users 1-800-325-0778), Monday through Friday from 7 a.m. to 7 p.m., or go to your local Social Security office.
What Are The Premiums For Medicare Part B?
Many who apply for Medicare may not have to pay a Part A premium if they or a spouse contributed through payroll deductions while working.
However, nearly everyone must pay a premium for Medicare Part B. Because Part B is based on your income level, your Medicare Part B cost can vary.
Most applicants pay a standard premium amount. If your modified adjusted gross income is more than a certain amount, you may pay an Income-Related Monthly Adjustment Amount (IRMAA). Medicare uses the modified adjusted gross income reported on your federal tax return from a two-year period.
When Do You Start Receiving Part B Coverage?
This depends on when and if you applied during your Initial Enrollment Period:
- If you applied one to three months before the age of 65, it starts the month you turn 65
- If you applied in your 65th birthday month, it starts the following month
- If you applied two to three months after turning 65, it starts three months after you sign up
- If you applied during the General Enrollment Period, which is January 1 to March 31, your coverage starts on July 1 of that year
Explore More Coverage Than Original Medicare (Part A And Part B)
Because Original Medicare doesn’t cover everything, it sometimes makes more sense to pick a plan that includes prescription drug coverage, and/or dental, vision, and hearing insurance. That’s why many people opt for a Medicare Advantage plan or Part D Plan. Be sure to consider all your coverage options.
Compare costs and find a Medicare plan that’s right for you.
If you have
Medicare
and other health insurance (like from a group health plan, retiree coverage, or Medicaid), each type of coverage is called a "payer." When there's more than one payer, "coordination of benefits" rules decide who pays first. The "primary payer" pays what it owes on your bills first, and then sends the rest to the "secondary payer" (supplemental payer) to pay. In some rare cases, there may also be a third payer.
What it means to pay primary/secondary
- The insurance that pays first (primary payer) pays up to the limits of its coverage.
- The one that pays second (secondary payer) only pays if there are costs the primary insurer didn't cover.
- The secondary payer (which may be Medicare) may not pay all the remaining costs.
- If your group health plan or retiree coverage is the secondary payer, you may need to enroll in Medicare Part B before they'll pay.
If the insurance company doesn't pay the
claim
promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should've made.
How Medicare coordinates with other coverage
If you have questions about who pays first, or if your coverage changes, call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627). Tell your doctor and other
health care provider
about any changes in your insurance or coverage when you get care.
I have Medicare and:
I'm 65 or older and have group health plan coverage based on my or my spouse's current employment status.- If the employer has 20 or more employees, then the group health plan pays first, and Medicare pays second.
If the
group health plandidn't pay all of your bill, the doctor or
health care providershould send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn't cover.
Employers with 20 or more employees must offer current employees 65 and older the same health benefits under the same conditions that they offer employees under 65. If the employer offers coverage to spouses, it must offer the same coverage to spouses 65 and older that they offer to spouses under 65.
- If the employer has less than 20 employees and isn't part of a multi-employer or multiple employer group health plan , then Medicare pays first, and the group health plan pays second.
- If the employer has less than 20 employees, the group health plan pays first, and Medicare pays second if both of these conditions apply:
- the employer is part of a multi-employer or multiple employer group health plan
at least one of the other employers has 20 or more employees
Check with your plan first and ask if it will pay first or second.
I'm in a Health Maintenance Organization (HMO) Plan or an employer Preferred Provider Organization (PPO) Plan that pays first, and I get services outside the group health plan's network.It's possible that neither the plan nor Medicare will pay if you get care outside your plan's network. Before you go outside the network, call your plan to find out if it will cover the service.
I dropped employer-offered coverage.If you’re 65 or older, Medicare pays first unless both of these apply:
- You have coverage through an employed spouse.
- Your spouse's employer has at least 20 employees.
Call your employer's benefits administrator for more information.
I'm 65 or older, retired, and have group health plan coverage from my spouse's current employer.Your spouse’s plan pays first, and Medicare pays second when all of these conditions apply:
- You’re retired, but your spouse is still working.
- You’re covered by your spouse’s group health plan coverage.
- Your spouse’s employer has 20 or more employees, or has less than 20 employees, but is part of a multi-employer plan or multiple employer plan.
If the group health plan doesn't pay all of a bill, the doctor or health care provider should send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn’t cover.
I'm under 65, disabled, retired and I have group health coverage from my former employer.If you're not currently employed, Medicare pays first, and your group health plan coverage pays second.
I'm under 65, disabled, retired and I have group health coverage from my family member's current employer.- If the employer has 100 or more employees, then your family member's group health plan pays first, and Medicare pays second.
- If the employer has less than 100 employees, but is part of a multi-employer or multiple employer group health plan, your family member's group health plan pays first and Medicare pays second.
- If the employer has less than 100 employees, and isn’t part of a multi-employer or multiple employer group health plan, then Medicare pays first, and your family member's group health plan pays second.
When you’re eligible for or entitled to Medicare because you have ESRD, your group health plan pays first, and Medicare pays second during a coordination period that lasts up to 30 months. You can have group health plan coverage or retiree coverage based on your employment or through a family member.
After the coordination period ends, Medicare pays first and your group health plan (or retiree coverage) pays second.
Whichever coverage paid first when you originally got Medicare will continue to pay first. You can have group health plan coverage or retiree coverage based on your employment or through a family member.
I have Medicare due to End-Stage Renal Disease (ESRD), and have COBRA coverage.When you’re eligible for or entitled to Medicare due to ESRD, COBRA pays first, and Medicare pays second during a coordination period that lasts up to 30 months after you're first eligible for Medicare. After the coordination period ends, Medicare pays first.
I get health care services from Indian Health Service (IHS) or an IHS provider.- If you have non-tribal group health plan coverage through an employer who has 20 or more employees, the non-tribal group health plan pays first, and Medicare pays second.
- If you have non-tribal group health plan coverage through an employer who has less than 20 employees, Medicare pays first, and the non-tribal group health plan pays second.
- If you have a group health plan through tribal self-insurance, Medicare pays first and the group health plan pays second.
No-fault insurance or liability insurance pays first and Medicare pays second.
If the no-fault or liability insurance denies your medical bill or is found not liable for payment, Medicare pays first, but only pays for Medicare-covered services. You're still responsible for your share of the bill (like
coinsurance, a
copaymentor a
deductible [glossary]) and for the cost of services Medicare doesn't cover.
If your provider knows you have a no-fault or liability insurance claim, they must try to get paid by the insurance company before billing Medicare. If the insurance company doesn't pay the claim promptly (usually within 120 days), your provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then will recover any payments the primary payer should have made later.
If Medicare makes a
conditional payment, and you get a settlement from an insurance company later, you're responsible for making sure Medicare gets repaid.
If you file a no-fault insurance or liability insurance claim and Medicare makes a conditional payment, you or your representative should report the claim and payment by calling the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627).
The Benefits Coordination & Recovery Center:
- Gathers information about conditional payments Medicare makes.
- Calculates the final amount owed (if any) on your recovery case.
- Send you a letter asking for repayment.
If you get a settlement, judgment, award or other payment, you or your representative should contact the Benefits Coordination & Recovery Center.
I'm covered under workers' compensation because of a job-related illness.Workers’ compensation pays first for services or items related to the workers’ compensation claim. Medicare may make a conditional payment if the workers’ compensation insurance company denies payment for your medical bills for 120 days or more, pending a review of your claim.
Find out more about how settling your claim affects Medicare payments.
I'm a Veteran and have Veterans' benefits.If you have (or can get) both Medicare and Veterans’ benefits, you can get treatment under either program. Generally, Medicare and the U.S. Department of Veterans Affairs (VA) can’t pay for the same service or items. Medicare pays for Medicare-covered services or items. The VA pays for VA-authorized services or items. Each time you get health care or see a doctor, you must choose which benefits to use.
For the VA to pay for services, you must go to a VA facility or have the VA authorize services in a non-VA facility.
If the VA authorizes services in a non-VA hospital, but didn’t authorize all of the services you get during your hospital stay, then Medicare may pay for any Medicare-covered services the VA didn’t authorize.
I'm covered under TRICARE.If you're on active duty and enrolled in Medicare, TRICARE pays first for Medicare-covered services or items, and Medicare pays second. If you're not on active duty, Medicare pays first for Medicare-covered services, and TRICARE may pay second.
If you get items or services from a military hospital or any other federal health care provider, TRICARE pays first.
Get more information on TRICARE.
For any health care related to black lung disease, the Federal Black Lung Program pays first as long as the program covers the service. Medicare won't pay for doctor or hospital services covered under the Federal Black Lung Program.
Your doctor or other health care provider should send all bills for the diagnosis or treatment of black lung disease to:
Federal Black Lung Program
PO Box 8302
London, KY 40742-8302
For all health care not related to black lung disease, Medicare pays first, and your doctor or health care provider should send your bills directly to Medicare.
If the Federal Black Lung Program won't pay your bill, ask your doctor or other health care provider to send Medicare the bill. Also ask them to include a copy of the letter from the Federal Black Lung Benefits Program explaining why they won’t pay your bill.
If you have questions about the Federal Black Lung Program, call 1-800-638-7072.
I have COBRA continuation coverage.If you have Medicare because you’re 65 or over or because you're under 65 and have a disability (not
End-Stage Renal Disease (Esrd)), Medicare pays first.
If you have Medicare due to ESRD, COBRA pays first and Medicare pays second during a coordination period that lasts up to 30 months after you’re first eligible for Medicare. After the coordination period ends, Medicare pays first.
Find out more in 7 facts about COBRA.
I have more than one other type of insurance or coverage.If you have Medicare and more than one other type of insurance, check your policy or coverage information for rules about who pays first. You can also call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627).
Tell your doctor and other health care providers if you have coverage in addition to Medicare. This will help them send your bills to the correct payer and avoid delays.
What's a conditional payment?
A conditional payment is a payment Medicare makes for services another payer may be responsible for. Medicare makes this conditional payment so you won't have to use your own money to pay the bill. The payment is "conditional" because it must be repaid to Medicare if you get a settlement, judgment, award, or other payment later.
You’re responsible for making sure Medicare gets repaid from the settlement, judgment, award, or other payment.
How Medicare recovers conditional payments
If Medicare makes a conditional payment, and you or your representative haven't reported your settlement, judgment, award or other payment to Medicare, call the Benefits Coordination & Recovery Center at 1-855-798-2627. (TTY: 1-855-797-2627).
The Benefits Coordination & Recovery Center:
- Gathers information about conditional payments Medicare makes.
- Calculates the final amount owed (if any) on your recovery case.
- Sends you a letter asking for repayment.