Medicare Part B

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Outpatient and other doctor services

Medicare Part B covers various outpatient medical services and other doctor services. Part B is a voluntary program and Medicare-eligible individuals must enroll in Medicare Part B in order to receive the programs benefits.

Medicare Part B covered services are reimbursed at 80% of the “reasonable charge” for the service. The individual receiving the service is responsible for paying the remaining 20%. However, this reasonable charge is determined by Medicare and may not adequately reflect the costs you pay to your physician.

When a doctor agrees to accept the Medicare-set “reasonable charge” as full payment, he or she is said to accept “assignment.” When a doctor does not accept “assignment,” the patient is responsible for paying the outstanding balance minus the Medicare-determined reimbursement. However, federal law sets a limit as to the maximum amount a doctor may bill for a service.

The maximum amount to be billed for a Medicare Part B covered service is 115% of the Medicare “reasonable charge.” If the doctor bills above this cap, he or she violates federal law.

Medicare Part B covers:

  • Diagnostic tests/lab work/screenings
  • Doctor services
  • Nursing services
  • Chemotherapy
  • Certain diabetic supplies
  • Flu and pneumonia vaccinations
  • Durable medical equipment
  • Some mammography and pap smear screening

Medicare Part B excludes:

  • Prescription drugs (that are not administered by a physician)
  • Hearing aids
  • Eye exams and eye glasses
  • Routine physical screenings