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Original Medicare: Doctor, Home Health and Preventive Care

AARP explains what Medicare pays and what you pay for doctor, home health care, and preventive care.

Medicare Part B helps pay for doctor bills, some home-health care, certain preventive services, outpatient hospital care, medical equipment and supplies, laboratory services, X-rays, physical therapy, mental health services, ambulance services, and blood. It does not pay all of these costs. You must pay some of these costs, too.

If you already get Social Security or Railroad Retirement benefits, you will automatically be enrolled in Part B and will begin paying monthly premiums. You must notify Social Security if you do not want this coverage. If you were not automatically enrolled and you would like to have Part B, you need to contact Social Security.

What You Pay Under Medicare Part B

 • Premium: A premium is the monthly payment for health insurance. Most people with Medicare will continue to pay the same $96.40 Part B premium in 2010 as they did in 2009. For others, including those newly enrolled in Medicare Part B, the Part B premium will be $110.50 in 2010. People with higher incomes will pay a higher premium. The premium can change every year. If you are receiving Social Security or Railroad Retirement benefits, the premium is taken out of your monthly checks. If not, Medicare sends you a bill every three months. For additional details, see Medicare’s FAQ on 2010 Part B Premium Amounts for Persons With Higher Income Levels.

 • Deductible: A deductible is the amount you must pay for your health care before Medicare starts to pay. The Medicare Part B deductible is $155 in 2010.

 • Coinsurance: Coinsurance is the percent you must pay for your health care. Usually it is 20 percent of the Medicare-approved amount for most doctor bills, other health care services, and medical equipment. The Medicare-approved amount is the amount Medicare decides is a reasonable payment for a medical service.

FYI: While signing up for Medicare Part B is your choice, it’s important to know the following facts:

• If you don’t sign up for Part B when you first go on Medicare, you may have to pay more for the Part B premium when you do sign up unless you or your spouse were working and had group health plan coverage through an employer or union. If the coverage or your employment ends (whichever is first), you have up to eight months to sign up for Part B without a penalty.

• After you are 65, once you sign up for Part B, you have six months to buy any Medicare Supplemental (Medigap) Insurance policy you choose, regardless of your health. This is called your open enrollment period. You only have this period once in your life. After this six-month period, you may not be able to buy the Medigap policy you want.

If you have questions or concerns about paying for Part B, talk to Medicare and your State Health Insurance Assistance Program (SHIP) before making a final decision.

Here is an example of what you might pay for a doctor visit:

In March, Joan saw her doctor for the first time that year. The bill for the doctor visit was $155, the Medicare-approved amount. Joan paid this $155 yearly Part B deductible.

In June, Joan goes to her doctor for a follow-up visit. The bill for this follow-up visit is $100. Since Joan has already paid her deductible, Medicare will now pay its share, $80 (80 percent of $100), and Joan will pay her share, $20 (20 percent of $100).

For her remaining doctor visits this year, Joan will pay 20 percent of the total bill and Medicare will pay 80 percent of the total bill.

In this example, Joan’s doctor "accepts assignment" with Medicare. This means that the doctor agrees not to charge more than the Medicare-approved amount.


What Medicare Part B Covers and What You Pay

Part B covers certain medical items and services. Costs for these services vary. For most of these items and services, a deductible and co-payments apply. Here is a chart of the doctor, medical, and preventive services covered by Medicare Part B.

Ambulance Services: 20 percent of the approved amount when an ambulance is needed to take you to or from a hospital or skilled nursing home.

Blood: 20 percent of the approved amount after you pay for the first three pints of blood you get as an outpatient or other Part B covered service.

Chiropractic Services: 20 percent of the approved amount for manipulation of the spine when one or more bones move out of position.

Diagnostic Tests: 20 percent of the approved amount for X-rays, MRIs, CT scans, EKGs, and other diagnostic tests as medically necessary.

Doctors: 20 percent of the approved amount for doctors' services, after you pay the yearly Part B deductible. Routine check-ups are not covered.

Durable Medical Equipment: 20 percent of the approved amount for most medical equipment after you pay the yearly Part B deductible. You must buy the equipment from suppliers approved by Medicare.

Emergency Room Services: 20 percent of the ER and doctor charges per visit. If you were admitted to the hospital for the same condition within 1-3 days, the emergency room visit will be part of your inpatient hospital charges.

Home Health Care: Nothing for approved services such as part-time skilled nursing care; physical, occupational, and speech therapy; home care, home health aides; medical social services; and other supplies and services.

Laboratory Tests: Nothing for approved services.

Mental Health Services: 50 percent of the approved amount for most outpatient mental health services.

Outpatient Hospital Care: 20 percent of the approved amount for most outpatient hospital care. Amount may vary according to the services received as an outpatient as part of a doctor’s care.

Preventive Services: Costs for the following services may vary depending on the type of plan you choose:

"Welcome to Medicare": A one-time physical exam within the first 12 months you have Part B. Coinsurance applies, but you do not have to pay a deductible for this service.

Cardiovascular screenings: Once every five years. You pay nothing.

Bone density measurement: Once every 24 months for people at risk for losing bone mass. 20 percent of the approved amount, after you pay the yearly Part B deductible.

Colorectal Cancer Screening: For people 50+.

Fecal Occult Blood Test: Once every 12 months if age 50 or older. You pay nothing for the test, but usually have to pay for the doctor visit.

Flexible Sigmoidoscopy: Once every 48 months. 20 percent of the approved amount, after you pay the yearly Part B deductible. 25 percent if done in a surgical center or hospital outpatient department.

Colonoscopy: Usually once every 10 years, and every 2 years for high risk individuals. 20 percent of the approved amount, after you pay the Part B deductible. 25 percent if done in a surgical center or hospital outpatient department.

Barium Enema: Doctor can decide to use instead of sigmoidoscopy or colonoscopy. 20 percent of the approved amount, after you pay the yearly Part B deductible.

Diabetes screening: Tests to check for diabetes if you have certain risk factors. You pay nothing for diabetes screening.

Diabetes care: Testing supplies and self-care training. 20 percent of the approved amount, after you pay the yearly Part B deductible.

Glaucoma screening: For people at high risk for glaucoma. Screening must be done by an eye doctor. 20 percent of the approved amount, after you pay the yearly Part B deductible.

Mammograms: For women 40+ once every 12 months. Women between 35 and 39 can get one baseline mammogram. 20 percent of the approved amount. The yearly Part B deductible does not apply.

Pap smears, pelvic and clinical breast exams: For all women every 24 months.

Pap Smear Test: You pay nothing.

Pap Smear Collection, Pelvic and Breast Exams: 20 percent of the approved amount. The yearly Part B deductible does not apply.

 

Prostate cancer screening: For men 50+ every 12 months

Digital rectal exam: 20 percent of the approved amount, after you pay the yearly Part B deductible.

PSA Test: You pay nothing. The yearly Part B deductible does not apply.

Shots: For all people with Medicare.

Flu Shot: once a year. You pay nothing.

Pneumonia: You may only need once. Check with your doctor. You pay nothing.

Hepatitis B: For those at risk for hepatitis. 20 percent of the approved amount, after you pay the yearly Part B deductible.

Services for Special Populations: Medicare covers additional services if you have conditions such as diabetes or kidney failure. For a complete list of additional services covered under Medicare Part B, go to: www.medicare.gov.

Therapeutic Equipment: 20 percent for medical equipment such as wheelchairs, walkers, and oxygen.

Therapeutic Services: 20 percent of the approved amount for outpatient physical or speech therapies up to an annual cap for the combined therapies. After the cap is reached, you pay 100 percent. There is a separate annual cap for occupational therapy.

Care at Home

Medicare Part A and Part B both help pay for home health care. Home health care is skilled nursing and other kinds of health care services that you get in your home to treat an illness or injury. (Medicare doesn’t pay for care to help with activities of daily living such as bathing, dressing, or using the toilet.)

You must meet four conditions for Medicare to help pay for your home health care:

1. Your doctor must order medical care for you in your home and make a plan for that care.

2. You must need help from a nurse or a physical, occupational, or speech therapist on a part-time basis. Medicare does not pay for these services round-the-clock (24 hours).

3. You must be homebound. This means it is very hard for you to leave your home because of your illness or injury.

4. You must get your care from a home-health care agency approved by Medicare.

Medicare pays for your home care for as long as you meet these conditions. Your doctor and home-health care agency will review your plan of care at least every 60 days.

What Medicare Pays
Medicare will pay for the following as part of your home health care:

• part-time skilled nursing care
• home-health aides
• physical, occupational, or speech therapists
• medical social services or counseling to help you cope with your illness or injury
• medical equipment and supplies

Medicare Part B Doesn’t Cover

• most outpatient prescription drugs
• routine check-ups
• most dental care
• hearing aids
• routine eye care
• routine foot care
• someone to help you bathe, dress, go to the bathroom, or eat meals at home and for an long period of time
• most chiropractic services 
• acupuncture
• health care when you travel outside the United States
• cosmetic (plastic) surgery

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