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Covered Services under Medicare Part B

Medical Benefits Covered under Medicare Part B

Medicare Part B helps cover medically-necessary services like doctors' services, outpatient care, and other medical services. The following table provides information on what is covered under Medicare Part B.

Source: Information from the official government handbook published by the Centers for Medicare and Medicaid Services: Medicare & You 2010 and 2011
Abdominal Aortic Aneurysm Screening A one-time screening ultrasound for people at risk. You must get a referral for it as part of your one-time "Welcome to Medicare" physical exam. Starting January 1, 2011, you pay nothing for the screening if the doctor accepts assignment.
Ambulance Services

Ground ambulance transportation when you need to be transported to a hospital or skilled nursing facility for medically-necessary services, and transportation in any other vehicle could endanger your health. Medicare may pay for ambulance transportation in an airplane or helicopter to a hospital if you need immediate and rapid ambulance transportation that ground transportation can't provide.

In some cases, Medicare may pay for limited non-emergency ambulance transportation if you have orders from your doctor saying that ambulance transportation is medically necessary. Medicare will only cover services to the nearest appropriate medical facility that is able to give you the care you need. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Ambulatory Surgical Centers Facility fees for approved surgical procedures provided in an ambulatory surgical center (facility where surgical procedures are performed, and the patient is released within 24 hours). Except for certain preventive services (for which you pay nothing), you pay 20% of the Medicare-approved amount to both the ambulatory surgical center and the doctor who treats you, and the Part B deductible applies. You pay all facility fees for procedures Medicare doesn't allow in ambulatory surgical centers.
Blood

In most cases, the provider gets blood from a blood bank at no charge, and you won't have to pay for it or replace it. However, you will pay a copayment for the blood processing and handling services for every unit of blood you get, and the Part B deductible applies. If the provider has to buy blood for you, you must either pay the provider costs for the first 3 units of blood you get in a calendar year or have the blood donated by you or someone else.

You pay a copayment for additional units of blood you get as an outpatient (after the first 3), and the Part B deductible applies.

Bone Mass Measurement (Bone Density) Helps to see if you're at risk for broken bones. This service is covered once every 24 months (more often if medically necessary) for people who have certain medical conditions or meet certain criteria. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment.
Cardiac Rehabilitation Medicare covers comprehensive programs that include exercise, education, and counseling for patients who meet certain conditions. Medicare also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than regular cardiac rehabilitation programs. You pay the doctor 20% of the Medicare-approved amount if you get the services in a doctor's office. In a hospital outpatient setting, you also pay the hospital a copayment.
Cardiovascular Screenings Blood tests that help detect conditions that may lead to a heart attack or stroke. This service is covered every 5 years to test your cholesterol, lipid, and triglyceride levels. You pay nothing for the tests, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.
Chiropractic Services (limited) Helps correct a subluxation (when one or more of the bones of your spine move out of position) using manipulation of the spine. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Note: You pay all costs for any other services or tests ordered by a chiropractor.
Clinical Laboratory Services Includes certain blood tests, urinalysis, some screening tests, and more. You pay nothing for these services, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.
Clinical Research Studies Tests how well different types of medical care work and if they are safe. Medicare covers some costs, like doctor visits and tests, in qualifying clinical research studies. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. Note: If you're in a Medicare Advantage Plan.
Colorectal Cancer Screenings To help find precancerous growths or find cancer early, when treatment is most effective. One or more of the following tests may be covered. Talk to your doctor.

  • Fecal Occult Blood Test-Once every 12 months if 50 or older. You pay nothing for the test, but you generally have to pay 20% of the Medicare-approved amount for the doctor's visit.
  • Flexible Sigmoidoscopy-Generally, once every 48 months if 50 or older, or 120 months after a previous screening colonoscopy for those not at high risk. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment.
  • Colonoscopy-Generally once every 120 months (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy. No minimum age. Starting January 1, 2011, you pay nothing for this test if the doctor accepts assignment.
  • Barium Enema-Once every 48 months if 50 or older (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy. You pay 20% of the Medicare-approved amount for the doctor's services. In a hospital outpatient setting, you also pay the hospital a copayment.

Note: If you get a screening flexible sigmoidoscopy or screening colonoscopy in an outpatient hospital setting or an ambulatory surgical center, you pay 25% of the Medicare-approved amount.
Defibrillator (Implantable Automatic) For some people diagnosed with heart failure. You pay the doctor 20% of the Medicare-approved amount for the doctor's services. You also pay the hospital a copayment but no more than the Part A hospital stay deductible if you get the device as a hospital outpatient. The Part B deductible applies.
Diabetes Screenings

Medicare covers these screenings if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes.

Based on the results of these tests, you may be eligible for up to two diabetes screenings every year. You pay nothing for the test, but you generally have to pay 20% of the Medicare?approved amount for the doctor's visit.

Diabetes Self-Management Training For people with diabetes with a written order from a doctor or other health care provider. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Diabetes Supplies

Includes blood sugar testing monitors, blood sugar test strips, lancet devices and lancets, blood sugar control solutions, and therapeutic shoes (in some cases). Insulin is covered only if used with an external insulin pump. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Note: Insulin and certain medical supplies used to inject insulin, such as syringes, and some oral diabetic drugs may be covered by Medicare prescription drug coverage (Part D).

Doctor Services Services that are medically necessary (includes outpatient and some doctor services you get when you're a hospital inpatient) or covered preventive services. Except for certain preventive services, you pay 20% of the Medicare?approved amount, and the Part B deductible applies.
Durable Medical Equipment (like walkers)

Items such as oxygen equipment and supplies, wheelchairs, walkers, and hospital beds ordered by a doctor or other health care provider enrolled in Medicare for use in the home. Some items must be rented. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. In all areas of the country, you must get your covered equipment or supplies and replacement or repair services from a Medicare?approved supplier for Medicare to pay.

For more information, visit http://go.usa.gov/loh to view a copy of "Medicare Coverage of Durable Medical Equipment and Other Devices." You can also call 1-800-MEDICARE (1-800-633-4227) to find out if a copy can be mailed to you. TTY users should call 1-877-486-2048.

New-Medicare is phasing in a new program called "competitive bidding" to help save you and Medicare money; ensure that you continue to get quality equipment, supplies, and services; and help limit fraud and abuse.In some areas of the country if you need certain items, you must use specific suppliers, or Medicare won't pay for the item and you likely will pay full price. It's important to see if you're affected by this new program to ensure Medicare payment and avoid any disruption of service.

This program starts January 1, 2011, in the following states:
CA, FL, IN, KS, KY, MO, NC, OH, PA, SC, TX

In certain areas in the states listed above, you need to use specific suppliers for Medicare to pay for the following items:

  • Oxygen supplies and equipment
  • Standard power wheelchair, scooter, and related accessories
  • Certain complex rehabilitative power wheelchairs and related accessories
  • Mail-order diabetes supplies
  • Enteral nutrients, equipment, and supplies
  • Hospital beds and related accessories
  • Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs) and related supplies and accessories
  • Walkers and related accessories
  • Support surfaces including certain mattresses and overlays (Miami, Fort Lauderdale, and Pompano Beach only)If you're currently renting or need durable medical equipment or supplies and have any questions about what's covered or about suppliers, you can get information in one of the following ways:
  • Visit www.medicare.gov/supplier. Medicare-approved suppliers are listed. The specific suppliers you need to use for this new program will have a symbol beside their names.
  • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
  • Call your State Health Insurance Assistance Program (SHIP) for free health insurance counseling and personalized help understanding these changes.

EKG Screening Medicare covers a one-time screening EKG if ordered by your doctor as part of your one-time "Welcome to Medicare" physical exam. You pay the doctor 20% of the Medicare-approved amount, and the Part B deductible applies. An EKG is also covered as a diagnostic test. If you have the test at a hospital or a hospital-owned clinic, you also pay the hospital a copayment.
Emergency Department Services When you have an injury, a sudden illness, or an illness that quickly gets much worse. You pay a specified copayment for the hospital emergency department visit, and you pay 20% of the Medicare-approved amount for the doctor's services. The Part B deductible applies.
Eyeglasses (limited) One pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Federally-Qualified Health Center Services Includes many outpatient primary care and preventive services you get through certain community-based organizations. Generally, you pay 20% of the Medicare-approved amount.
Flu Shots Generally covered once per flu season in the fall or winter. You pay nothing for the flu shot if the doctor or other health care provider accepts assignment for giving the shot. Note: Medicare Part B also covers administration of the H1N1 flu shot. You pay nothing if your doctor accepts assignment for giving the shot.
Foot Exams and Treatment If you have diabetes-related nerve damage and/or meet certain conditions. You pay the doctor 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you also pay the hospital a copayment.
Glaucoma Tests Covered once every 12 months for people at high risk for the eye disease glaucoma. You're at high risk if you have diabetes, a family history of glaucoma, are African-American and 50 or older, or are Hispanic and 65 or older. An eye doctor who is legally allowed by the state must do the tests. You pay the doctor 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor's visit. In a hospital outpatient setting, you also pay the hospital a copayment.
Hearing and Balance Exams

If your doctor orders these tests to see if you need medical treatment. You pay the doctor 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you also pay the hospital a copayment.

Note: Medicare doesn't cover hearing aids and exams for fitting hearing aids.

Hepatitis B Shots Covered for people at high or medium risk for Hepatitis B. Your risk for Hepatitis B increases if you have hemophilia, End-Stage Renal Disease (ESRD), or certain conditions that increase your risk for infection. Other factors may increase your risk for Hepatitis B, so check with your doctor. You pay nothing for the shot if the doctor accepts assignment.
HIV Screening Medicare covers HIV (Human Immunodeficiency Virus) screening for people with Medicare of any age who ask for the test, pregnant women, and people at increased risk for the infection. Medicare covers this test once every 12 months or up to 3 times during a pregnancy. You pay nothing for the test, but you generally have to pay the doctor 20% of the Medicare?approved amount for the doctor's visit.
Home Health Services Covers medically-necessary part-time or intermittent skilled nursing care, or physical therapy, speech-language pathology, or a continuing need for occupational therapy. A doctor or other health care provider enrolled in Medicare must order the care, and a Medicare-certified home health agency must provide it. Home health services may also include medical social services, part-time or intermittent home health aide services, durable medical equipment, and medical supplies for use at home. You must be homebound, which means that leaving home is a major effort. You pay nothing for covered home health services. For Medicare-covered durable medical equipment information.
Kidney Dialysis Services and Supplies For people with End-Stage Renal Disease (ESRD). Medicare covers dialysis either in a facility or at home when your doctor orders it. You pay 20% of the Medicare-approved amount per session, and the Part B deductible applies.
Kidney Disease Education Services Medicare may cover up to six sessions of kidney disease education services if you have Stage IV chronic kidney disease, and your doctor refers you for the service. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Mammograms (screening) A type of X-ray to check women for breast cancer. Medicare covers screening mammograms once every 12 months for women 40 and older. Medicare covers one baseline mammogram for women between 35-39. Starting January 1, 2011, you pay nothing for the test if the doctor accepts assignment.
Medical Nutrition Therapy Services Medicare may cover medical nutrition therapy and certain related services if you have diabetes or kidney disease, or you have had a kidney transplant in the last 36 months, and your doctor refers you for the service. Starting January 1, 2011, you pay nothing for these services if the doctor accepts assignment.
Mental Health Care (outpatient)

To get help with mental health conditions such as depression or anxiety. Includes services generally given outside a hospital or in a hospital outpatient setting, including visits with a psychiatrist or other doctor, clinical psychologist, nurse practitioner, physician's assistant, clinical nurse specialist, or clinical social worker; substance abuse services; and lab tests. Certain limits and conditions apply.

What you pay will depend on whether you're being diagnosed and monitored or whether you're getting treatment.

  • For visits to a doctor or other health care provider to diagnose your condition, you pay 20% of the Medicare-approved amount.
  • For outpatient treatment of your condition (such as counseling or psychotherapy), you pay 45% of the Medicare-approved amount in 2011. This coinsurance amount will continue to decrease over the next 3 years.

The Part B deductible applies for both visits to diagnose or treat your condition.

Note: Inpatient mental health care is covered under Part A hospital stays.

Talk to your doctor if you feel sad, have little interest in things you used to enjoy, feel dependent on drugs or alcohol, or have thoughts about ending your life.

Non-doctor Services Medicare covers services provided by certain non-doctors, such as physician assistants, nurse practitioners, social workers, physical therapists, and psychologists. Except for certain preventive services, you pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Occupational Therapy Evaluation and treatment to help you return to usual activities (such as dressing or bathing) after an illness or accident when your doctor certifies you need it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Outpatient Medical and Surgical Services and Supplies For approved procedures (like X-rays, a cast, or stitches). You pay the doctor 20% of the Medicare-approved amount for the doctor's services. You also pay the hospital a copayment for each service you get in a hospital outpatient setting. For each service, the copayment can't be more than the Part A hospital stay deductible. The Part B deductible applies, and you pay all charges for items or services that Medicare doesn't cover.
Pap Tests and Pelvic Exams (includes clinical breast exam) Checks for cervical, vaginal, and breast cancers. Medicare covers these screening tests once every 24 months, or once every 12 months for women at high risk, and for women who have Medicare and are of child-bearing age who have had an exam that indicated cancer or other abnormalities in the past 3 years. You pay nothing for the Pap lab test. Starting January 1, 2011, you also pay nothing for Pap test specimen collection, and pelvic and breast exams if the doctor accepts assignment.

Physical Exams

Note: Your first yearly "Wellness" exam can't take place within 12 months of your "Welcome to Medicare" physical exam.

Medicare covers two types of physical exams-one when you're new to Medicare and one each year after that.

  • "Welcome to Medicare" physical exam-A one-time review of your health, education and counseling about preventive services, and referrals for other care if needed. Medicare will cover this exam if you get it within the first 12 months you have Part B. Starting January 1, 2011, you pay nothing for the exam if the doctor accepts assignment. When you make your appointment, let your doctor's office know that you would like to schedule your "Welcome to Medicare" physical exam.Keep in mind, you don't need to get the "Welcome to Medicare" physical exam before getting a yearly "Wellness" exam.
  • Yearly "Wellness" exam-If you've had Part B for longer than 12 months, starting January 1, 2011, you can get a yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. You pay nothing for this exam if the doctor accepts assignment. This exam is covered once every 12 months.

Physical Therapy Evaluation and treatment for injuries and diseases that change your ability to function when your doctor certifies your need for it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Pneumococcal Shot Helps prevent pneumococcal infections (like certain types of pneumonia). Most people only need this shot once in their lifetime. Talk with your doctor. You pay nothing if the doctor or supplier accepts assignment for giving the shot.
Prescription Drugs (limited)

Includes a limited number of drugs such as injections you get in a doctor's office, certain oral cancer drugs, drugs used with some types of durable medical equipment (like a nebulizer or external infusion pump) and under very limited circumstances, certain drugs you get in a hospital outpatient setting. You pay 20% of the Medicare-approved amount for these covered drugs.

If the covered drugs you get in a hospital outpatient setting are part of your outpatient services, you pay the copayment for the services. However, if you get other types of drugs in a hospital outpatient setting (sometimes called "self?administered drugs" or drugs you would normally take on your own), what you pay depends on whether you have Part D or other prescription drug coverage, whether your drug plan covers the drug, and whether the hospital's pharmacy is in your drug plan's network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting that aren't covered under Part B.

Other than the examples above, you pay 100% for most prescription drugs, unless you have Part D or other drug coverage.

Prostate Cancer Screenings Medicare covers a digital rectal exam and Prostate Specific Antigen (PSA) test once every 12 months for men over 50 (coverage for this test begins the day after your 50th birthday). You pay nothing for the PSA test. You pay the doctor 20% of the Medicare-approved amount, and the Part B deductible applies for the doctor's visit. In a hospital outpatient setting, you also pay the hospital a copayment.
Prosthetic/ Orthotic Items Includes arm, leg, back, and neck braces; artificial eyes; artificial limbs (and their replacement parts); some types of breast prostheses (after mastectomy); and prosthetic devices needed to replace an internal body part or function (including ostomy supplies, and parenteral and enteral nutrition therapy) when your doctor orders it. For Medicare to cover your prosthetic or orthotic, you must go to a supplier that is enrolled in Medicare. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Pulmonary Rehabilitation Medicare covers a comprehensive pulmonary rehabilitation program if you have moderate to very severe chronic obstructive pulmonary disease (COPD) and have a referral from the doctor treating your chronic respiratory disease. You pay the doctor 20% of the Medicare-approved amount if you get the service in a doctor's office. You also pay the hospital a copayment per session if you get the service in a hospital outpatient setting.
Rural Health Clinic Services Includes many outpatient primary care services. You pay 20% of the amount charged, and the Part B deductible applies.
Second Surgical Opinions Covered in some cases for surgery that isn't an emergency. In some cases, Medicare covers third surgical opinions. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Smoking Cessation (counseling to stop smoking)

Includes up to 8 face-to-face visits in a 12-month period if you're diagnosed with an illness caused or complicated by tobacco use, or you take a medicine that is affected by tobacco. You pay the doctor 20% of the Medicare-approved amount, and the Part B deductible applies. In a hospital outpatient setting, you also pay the hospital a copayment.

Medicare coverage of smoking cessation counseling is now considered a covered preventive service if you haven't been diagnosed with an illness caused or complicated by tobacco use. Starting January 1, 2011 you pay nothing for the counseling sessions.

Speech-Language Pathology Services Evaluation and treatment given to regain and strengthen speech and language skills including cognitive and swallowing skills when your doctor certifies you need it. There may be limits on these services and exceptions to these limits. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.
Surgical Dressing Services For treatment of a surgical or surgically-treated wound. You pay 20% of the Medicare-approved amount for the doctor's services. You pay a fixed copayment for these services when you get them in a hospital outpatient setting. You pay nothing for the supplies. The Part B deductible applies.
Telehealth Includes a limited number of medical or other health services, like office visits and consultations provided using an interactive two-way telecommunications system (like real-time audio and video) by an eligible provider who isn't at your location. Available in some rural areas, under certain conditions, and only if you're located at one of the following places: a doctor's office, hospital, rural health clinic, federally-qualified health center, hospital-based dialysis facility, skilled nursing facility, or community mental health center. You pay 20% of the Medicare?approved amount, and the Part B deductible applies.
Tests (other than lab tests) Includes X-rays, MRIs, CT scans, EKGs, and some other diagnostic tests. You pay 20% of the Medicare-approved amount, and the Part B deductible applies. If you get the test at a hospital as an outpatient, you also pay the hospital a copayment that may be more than 20% of the Medicare-approved amount, but it can't be more than the Part A hospital stay deductible. See "Clinical Laboratory Services&quot.
Transplants and Immunosuppressive Drugs

Includes doctor services for heart, lung, kidney, pancreas, intestine, and liver transplants under certain conditions and only in a Medicare-certified facility. Medicare covers bone marrow and cornea transplants under certain conditions.

Immunosuppressive drugs are covered if Medicare paid for the transplant, or an employer or union group health plan was required to pay before Medicare paid for the transplant. You must have been entitled to Part A at the time of the transplant, and you must be entitled to Part B at the time you get immunosuppressive drugs. You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

If you're thinking about joining a Medicare Advantage Plan and are on a transplant waiting list or believe you need a transplant, check with the plan before you join to make sure your doctors and hospitals are in the plan's network. Also, check the plan's coverage rules for prior authorization.

Note: Medicare drug plans (Part D) may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn't pay for the transplant.

Travel (health care needed when traveling outside the United States)

Medicare generally doesn't cover health care while you're traveling outside the U.S. (the "U.S." includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). There are some exceptions including some cases where Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the U.S. Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign country in the following rare cases:

1. hospital is closer than the nearest U.S. hospital that can treat your medical condition

2. If you're traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency

3. If you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists

Medicare may cover medically-necessary ambulance transportation to a foreign hospital only with admission for medically-necessary covered inpatient hospital services.

You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Urgently-Needed Care To treat a sudden illness or injury that isn't a medical emergency. You pay the doctor 20% of the Medicare?approved amount for the doctor's services, and the Part B deductible applies. In a hospital outpatient setting, you also pay the hospital a copayment.
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