Understanding Medicare Part B: What It Covers
Medicare Part B is a type of health insurance that covers outpatient medical services. Unlike Part A, which focuses on hospital stays, Part B pays for doctor visits, outpatient procedures, and certain medical equipment you use at home. Understanding what Part B covers helps you know what costs you might expect when you receive medical care.
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Part B covers doctor visits to your primary care physician and specialists like cardiologists, dermatologists, and orthopedic surgeons. When you visit a doctor who participates in Medicare, Part B typically pays 80% of the approved amount after you meet your deductible. This means you generally pay 20% of the cost as your coinsurance.
Outpatient hospital services fall under Part B coverage as well. This includes emergency room visits, observation stays, and same-day surgery performed at a hospital rather than in a doctor's office. If you need lab tests or X-rays at an outpatient facility, Part B covers those services too, though you may have additional out-of-pocket costs.
Part B also covers durable medical equipment (DME) such as wheelchairs, walkers, oxygen equipment, and diabetic testing supplies. The program pays 80% of the Medicare-approved amount for this equipment after your deductible. Some items require prior authorization before purchase to ensure they meet medical necessity standards.
Mental health services, including therapy and psychiatric visits, receive coverage through Part B. This includes both individual counseling and group therapy sessions. Physical therapy and occupational therapy also fall under Part B coverage when medically necessary and ordered by a doctor.
Practical Takeaway: Keep a list of the types of services you use regularly—such as doctor visits, lab work, or therapy—and cross-reference them against Part B's coverage areas to understand your potential out-of-pocket costs.
Monthly Premiums and Deductibles Explained
Part B requires you to pay a monthly premium, which is the cost of having this coverage. As of 2024, the standard monthly premium is $174.70 for most beneficiaries. However, your actual premium may be different based on your income level. Higher-income individuals pay more through a program called Income-Related Monthly Adjustment Amounts (IRMAA).
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Income thresholds for IRMAA are based on your modified adjusted gross income from two years prior. For example, premiums collected in 2024 are based on income from 2022. If your income exceeds certain thresholds, you pay an additional amount on top of the standard premium. A person with income over $194,000 (filing individually) may pay significantly more—potentially up to $560.50 per month in 2024.
Beyond the premium, Part B has an annual deductible. For 2024, the deductible is $240. This means you must pay $240 out of your own pocket for Part B-covered services before Medicare starts paying its share. After you meet the deductible, you typically pay 20% coinsurance for most services while Medicare covers 80%.
Some services have different cost structures. Preventive care services, such as annual wellness visits and certain screenings, are covered at 100% after you meet the deductible. This includes mammograms, colonoscopies, and cardiovascular screenings. Mental health services have a different coinsurance rate than general medical services in some cases.
If you have a supplemental insurance plan (Medigap) or Medicare Advantage plan, your out-of-pocket costs work differently. These plans may cover your deductible, premium, or coinsurance amounts, though premiums and coverage details vary by plan.
Practical Takeaway: Review your income from two years ago to estimate whether IRMAA adjustments may apply to your premium, and budget the $240 annual deductible into your healthcare expenses.
Coinsurance Costs for Different Types of Services
After you meet your annual deductible, Part B typically requires you to pay 20% of the Medicare-approved amount for most services, with Medicare paying the remaining 80%. This 20% payment is called coinsurance. Understanding which services charge coinsurance helps you anticipate costs for specific medical needs.
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A typical doctor visit might have a Medicare-approved amount of $150. After your deductible is met, you would pay $30 (20%) and Medicare pays $120 (80%). However, if your doctor does not participate in Medicare, costs can be substantially higher. Non-participating doctors may charge up to 15% more than the Medicare-approved amount, and you pay the full difference plus your coinsurance.
Outpatient surgery and procedures follow the same 20% coinsurance rule. If you have a minor surgical procedure in an outpatient setting with an approved amount of $1,000, you would pay $200 as coinsurance after your deductible. Hospital outpatient department charges may be higher than the same procedure performed in a doctor's office, which is important to know when choosing where to receive care.
Diagnostic services like lab work and imaging tests also follow the 20% coinsurance rule. A single MRI might cost $1,500 as the Medicare-approved amount, resulting in a $300 coinsurance payment from you. However, preventive screening tests—such as one colonoscopy every 10 years or one mammogram annually—are covered at 100% with no coinsurance.
Durable medical equipment coinsurance works similarly. If you need a power wheelchair with an approved amount of $2,000, you pay $400 and Medicare covers $1,600. Some DME items have rental options, which may cost less than purchasing if you need them for a short time.
Practical Takeaway: Request the Medicare-approved amount for any planned procedure from your provider before the service, then calculate your 20% coinsurance to set aside funds for the visit.
What Part B Does Not Cover
Part B has significant coverage gaps that you should understand to avoid unexpected bills. Knowing what is not covered helps you make informed decisions about supplemental insurance or alternative payment plans. Many services that might seem medically necessary are simply not included in Part B.
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Routine dental care, including cleanings, fillings, and extractions, is not covered by Part B. Dental services fall outside Medicare's scope entirely unless you are hospitalized and require emergency dental care as part of that hospital stay. If you need dentures or other dental prosthetics, you pay the full cost out of pocket. This can be a significant expense, with a full set of dentures costing $500 to $3,000 or more.
Vision care including eye exams for glasses or contacts is not covered by Part B. However, exams to diagnose or treat eye diseases like glaucoma or cataracts are covered. After cataract surgery, Part B covers one pair of glasses or contact lenses. Routine eyeglasses, sunglasses, or contact lenses for distance or reading are your responsibility.
Hearing aids and hearing exams for the purpose of fitting hearing aids are not covered. A basic hearing aid can cost $1,000 to $6,000 per ear, making this a substantial out-of-pocket expense. Some state programs or nonprofit organizations may offer assistance with hearing aid costs, but Medicare does not.
Routine foot care, including toenail trimming and removal of calluses, is not covered unless you have diabetes or another condition that affects circulation. Long-term care, such as custodial care in a nursing home or assisted living facility, is not covered by Part B. Many people assume Medicare covers nursing home care, but it generally does not unless you are receiving skilled nursing care following a hospital stay.
Cosmetic procedures are never covered, even if they have some medical benefit. Certain prescription drugs that are self-administered at home are covered under Part D (prescription drug coverage), not Part B. Experimental treatments and services deemed not medically necessary by Medicare are also excluded from coverage.
Practical Takeaway: Request a written list from your provider stating which services are not covered by Medicare before scheduling elective procedures, and explore supplemental insurance options for commonly needed services like dental or vision care.
Cost-Sharing With Participating vs. Non-Participating Providers
Medicare providers fall into two