Part B medical insurance is intended to cover basic medical services provided by doctors, clinics, and laboratories. The lists of services specifically covered and not covered are long, and do not always make a lot of common sense. Making the effort to learn what is and is not covered can be important, because you may get the most benefits by fitting your medical treatments into the covered categories whenever possible. (For an explanation of how much of your covered costs Part B pays, see our article on what you pay for Medicare Part B services.)
Here are the services that Medicare Part B pays for.
Part B medical insurance covers medically necessary doctors’ services, including surgery, whether the services are provided at the hospital, at a doctor’s office, or—if you can find such a doctor—at home. Part B also covers outpatient medical services provided by hospital and doctor’s office staff who assist in providing care, such as nurses, nurse practitioners, surgical assistants, and laboratory or X-ray technicians.
Outpatient Care and Laboratory Testing
Medicare medical insurance covers outpatient hospital treatment, such as emergency room or clinic charges, X-rays, injections that are not self-administered, and laboratory work and diagnostic tests. Lab work and tests can be done at the hospital lab or at an independent laboratory facility, as long as that lab is approved by Medicare.
Beware: Medicare pays only a limited amount of outpatient hospital and clinic bills. Unlike most other kinds of services, Medicare places no limits on how much the hospital or clinic can charge for outpatient services over and above what Medicare pays.
Part B medical insurance will cover the cost of transporting a patient by ambulance, if transport by any other means would not be medically advisable. This may include not only emergencies, but also nonemergency trips following discharge from a hospital—for example, to the patient’s home or to a nursing facility. Transporting residents of nursing facilities to see their doctors may also be covered. However, Medicare does not cover ambulance transport for regular visits from a person’s home to a doctor’s office, if the trip was arranged simply because the person needed some assistance.
If your doctor prescribes an ambulance for you for a trip from home to the doctor’s office, Medicare may cover it but is not required to. Medicare will cover the ambulance trip only if the doctor’s communication with Medicare convinces Medicare that the ambulance was medically necessary.
If Medicare covers an ambulance trip, the ambulance company must accept the Medicare-approved amount as full payment for its services. Medicare will pay 80% of that amount. You, or your medigap insurer or Medicare Advantage plan, are responsible for paying the remaining 20%. The ambulance company may not bill you for any amount over that 20%.
Drugs or other medicines administered to you at the hospital or doctor’s office are covered by medical insurance. Medicare Part B does not cover drugs you take by yourself at home, including self-administered injections, even if they are prescribed by your doctor. Exceptions to this rule are self-administered oral cancer medication, antigens, and immunosuppressive drugs, which are covered by Medicare. Also, flu shots and pneumonia vaccines are covered by Medicare, even though other vaccinations are not; the flu shot you can obtain on your own, but the pneumonia vaccination requires a doctor’s prescription.
Medical Equipment and Supplies
Splints, casts, prosthetic devices, body braces, heart pacemakers, corrective lenses after a cataract operation, therapeutic shoes for diabetics, and medical equipment such as ventilators, wheelchairs, and hospital beds— if prescribed by a doctor—are all covered by Part B medical insurance. This includes glucose monitoring equipment for people who have diabetes.
To learn more about the many types of medical equipment and supplies Medicare Part B covers, and how different equipment may be rented or purchased, see Medicare’s online publication Medicare Coverage of Durable Medical Equipment and Other Devices. To find a Medicare-certified supplier of medical equipment near you, go to the Medicare website home page at www.medicare.gov and click on “Help & Resources" and then "Where to get covered medical items."
Some types of surgery on the jaw or facial bones, or on the related nerves or blood vessels, can be covered by Part B medical insurance. However, surgery on teeth or gums, even when related to an injury or a disease that did not originate with the teeth, is usually considered to be dental work, and so is not covered by Medicare.
Although normal dental care is not covered by Medicare, damage to teeth or gums connected to an injury or disease is a medical as much as a dental problem. However, there is one route to coverage: If the work is done by a dentist or oral surgeon, Medicare will cover it if physicians also provide the same kind of care and if Medicare would cover the care if a doctor had provided it. This is usually determined by whether the treatment involves just the teeth and gums (not covered) or also the bones, inside mouth, blood vessels, or tongue (covered).
Outpatient Physical Therapy and Speech Therapy
Part B of Medicare will cover some of the cost of outpatient physical and speech therapy—if it is prescribed and regularly reviewed by a doctor and provided by a Medicare-approved facility or therapist. However, there are limits on how much Medicare will pay for these therapies. And the amount Medicare pays will be partially determined by who provides you with the services. These limits are explained in our article on Medicare payments for outpatient therapies.
Home Health Care
The same home health care coverage is available under Part B medical insurance as is provided by Part A hospital insurance. (See our article on Medicare coverage of home health care.)
There is no limit on the number of home health care visits that are covered, and you are not responsible for your Part B deductible for home health care. Only skilled nursing care or therapy while you are confined to your home is covered, however, and such care must be ordered by your doctor and provided by a Medicare-approved home health care agency.
Part B medical insurance, like Part A coverage, will pay 100% of the approved charges of a participating home health care agency. If you have both Part A and Part B, Part A will cover your home health care following a hospital stay of at least three days; otherwise, Part B will cover it.
Part B may cover some care by a Medicare-certified chiropractor. Generally, Medicare will cover a limited number of visits to a chiropractor for manipulation of neck or back vertebrae that are out of place. Medicare will not, however, cover general health maintenance visits to a chiropractor, nor will it usually cover therapeutic manipulation other than of the vertebrae. And Medicare generally will not cover X-rays or other diagnostic tests done by the chiropractor. Instead, your physician normally must order these tests.
If you go to a chiropractor and hope to have Medicare pay its share of the bill, have the chiropractor’s office check with Medicare ahead of time about the treatment being proposed. Even if Medicare initially agrees to covers the treatment, it may not do so indefinitely. So, if you continue with the treatments, have the chiropractor’s office regularly check with Medicare to find out how long it will keep paying.
Preventive Screening Exams
Medicare covers the following examinations to screen for a number of serious illnesses:
- a one-time routine physical exam (sometimes called an “initial wellness exam”) within six months of the date a person first enrolls in Part B coverage
- an annual physical exam that includes a comprehensive risk assessment, which may lead to further Medicare-covered testing
- a Pap smear and pelvic exam every three years; every year for women at high risk of cervical or pelvic disease; Medicare covers this exam even if you have not yet met your annual Part B deductible
- colorectal cancer screening, as your physician deems necessary
- bone density tests for women at high risk of developing osteoporosis or for anyone receiving long-term steroid therapy, who has primary hyperparathyroidism, or who has certain vertebrate abnormalities
- blood glucose testing supplies—if prescribed by a physician—for patients with diabetes
- annual prostate cancer screenings for men over 55
- annual flu shot, with no deductible and no coinsurance amount
- positron emission tomography (PET) scans, a diagnostic test for certain cancers
- annual eye screening for glaucoma
- blood screening for early detection of cardiovascular disease, if your doctor says you have risk factors
- screening test for diabetes, if your doctor says you’re at risk for the disease, and
- PET brain scans for patients with unusual Alzheimer’s-like symptoms, if your doctor believes the source may be a different type of brain disease known as “frontotemporal dementia.”
Part B covers a yearly mammogram, even if you have not yet met your annual deductible. The mammogram must be performed by your doctor or by a facility certified for mammography by Medicare.
Medicare covers podiatrist services only when they consist of treatment for injuries or diseases of the foot. This does not include routine foot care or treatment of corns or calluses.
Medicare does not cover routine eye examinations, glasses, or contact lenses. The only exception is for people who have undergone cataract or other eye surgery. For them, Medicare covers glasses, contact lenses, or intraocular lenses, as well as the cost of an examination by a Medicare-certified optometrist.
Clinical Psychologists or Social Workers
When a doctor or hospital prescribes it in conjunction with medical treatment, Medicare Part B can cover limited counseling by a clinical psychologist or clinical social worker. The practitioner must be Medicare-approved. If your doctor suggests a clinical psychologist or social worker to help in your recovery from surgery, injury, or illness, contact the practitioner in advance to find out whether the services will be approved by Medicare.
Day Care Mental Health Treatment
Medicare Part B can cover mental health care, in the form of day treatment—also called partial hospitalization—at a hospital outpatient department or community mental health center. The facility must be Medicare-approved and the particular day program certified for Part B coverage by Medicare.
Until recently, Medicare did not cover various kinds of physical, speech, and occupational therapy, or psychotherapy and other mental health services, for people who had been diagnosed with Alzheimer’s disease. Medicare’s reasoning was that patients with Alzheimer’s were incapable of medically improving, and that the treatment was therefore not “medically necessary.”
Medicare has now reversed its stance and a patient can no longer be denied Medicare coverage for physician-prescribed therapies or treatments solely because the patient has been diagnosed with Alzheimer’s.
Until mid-2004, Medicare had refused to recognize obesity as a disease and therefore had failed to cover any treatments for it. Now, however, Medicare has reversed its position and will cover various scientifically proven weight-loss therapies and treatments. These range from stomach surgeries to diet programs to psychological and behavior-modification counseling. Not all treatments are covered, and not all patients will be eligible for all covered treatments. But if you are undergoing care from a physician for obesity, the physician can recommend a specific treatment for you and submit it to Medicare for coverage approval.
To learn what services Medicare Part B won't cover, see our article on services not covered by Medicare Part B.
by: Attorney Joseph Matthews