What is the cost to enrollees?
In 2016, most individuals (about 70% of Medicare beneficiaries) will continue to pay $104.90 per month for Medicare Part B, the same standard premium they paid in 2013, 2014, and 2015. If you fall into this category, your premium won't rise because you won't be receiving a Social Security cost-of-living allowance (COLA) increase in your benefit for 2016. Due to a provision in the Social Security Act, you are "held harmless" from Part B premium increases when no Social Security COLA is payable.
Unfortunately, this is not the case for the approximately 30% of Medicare beneficiaries who are not subject to this "hold harmless" provision. You fall into this group and will pay more for Medicare Part B in 2016 if:
- You enroll in Part B for the first time in 2016.
- You don't get Social Security benefits.
- You have Medicare and Medicaid, and Medicaid pays your premiums.
- Your modified adjusted gross income as reported on your federal income tax return from two years ago is above a certain amount.*
The table below shows what you'll pay in 2016 if you're in this group.
|Beneficiaries who file an individual income tax return with income that is:||Beneficiaries who file a joint income tax return with income that is:||Beneficiaries who file an income tax return as married filing separately with income that is:||Monthly premium in 2015:||Monthly premium in 2016:|
|$85,000 or less||$170,000 or less||$85,000 or less||$104.90||$121.80|
|Above $85,000 up to $107,000||Above $170,000 up to $214,000||N/A||$146.90||$170.50|
|Above $107,000 up to $160,000||Above $214,000 up to $320,000||N/A||$209.80||$243.60|
|Above $160,000 up to $214,000||Above $320,000 up to $428,000||Above $85,000 up to $129,000||$272.70||$316.70|
|Above $214,000||Above $428,000||Above $129,000||$335.70||$389.80|
*Beneficiaries with higher incomes have paid higher Medicare Part B premiums since 2007. To determine if you're subject to income-related premiums, the SSA uses the most recent federal tax return provided by the IRS. Generally, the tax return you filed in 2015 (based on 2014 income) will be used to determine if you will pay an income-related premium in 2016 (your 2013 income was used for 2015 premiums). You can contact the SSA at (800) 772-1213 if you have new information to report that might change the determination and lower your premium (you lost your job and your income has gone down or you've filed an amended income tax return, for example).
The Medicare Part B deductible is $166 in 2016.
What does Medicare Part B cover?
Medical care that is not inpatient is usually covered under Medicare Part B. Medicare Part B covers 80 percent of medically necessary physician or outpatient charges, including charges from a physician for care received in a hospital. The Part B deductible generally applies.
Services covered under Medicare Part B
Currently, services covered under Medicare Part B (the 20 percent coinsurance charge and deductible generally apply) include:
- Physician and surgeon fees
- Outpatient services
- Immunosuppressive drugs
- Blood service, after you pay for the first three pints of blood in any calendar year
- Clinical laboratory services
- Some coverage for outpatient mental health visits
- Certain medically-necessary home health services
- Physical and occupational therapy
- Ambulance service
Medicare also fully covers the cost of most preventive services (beneficiaries will pay nothing out-of-pocket) if a health-care provider accepts Medicare assignments. Some services are limited to one per year. The preventive services Medicare fully covers include:
- An annual wellness exam to develop or update a personalized prevention plan
- Annual mammograms for individuals age 40 or older, and a baseline mammogram for individuals between ages 35 and 39
- Pap test and pelvic exams
- Pneumococcal and flu vaccines
- Hepatitis B vaccines for high-risk individuals
- HIV screening test
- Colorectal cancer screening test
- Diabetes screening test
- Cardiovascular screening test
- Bone density measurements for women at risk for osteoporosis
- Self-management training for individuals with diabetes
- Medical nutrition therapy for individuals with diabetes or kidney disease
- Smoking cessation counseling if you haven't yet been diagnosed with a tobacco-related illness
- Depression screening (test is fully covered; you generally have to pay 20 percent for doctor's visit)
- Alcohol misuse screening and counseling
- Obesity screening and counseling
Services excluded from Medicare Part B coverage
In general, Medicare pays only for services it considers reasonable or medically necessary. Specific exclusions include:
- Cosmetic surgery, unless particular medical conditions render it necessary
- Procedures considered experimental
- Hearing aids and fittings
- Chiropractic services, except for treatment of subluxation (partial dislocation) of the spine
- Most eyeglasses and eye exams
- Most dentures and dental care
- Prescription drugs you administer yourself, such as those you buy at a drug store and take at home (exceptions are immunosuppressive drugs and antirejection drugs for kidney transplant patients)
- Over-the-counter drugs
- Care outside of the United States (except when a Mexican or Canadian hospital is closer, such as in an emergency, even though you reside in the United States, or if you require care while traveling through Canada en route to Alaska)
Prescription drug coverage is available under Medicare Part D (prescription drug coverage).
Medicare regulations specifying what it will cover almost always begin with a general rule, followed by exceptions. If you are denied coverage, it is always wise to look into whether or not you can meet one of the exceptions.
You can get further information about coverage under Medicare Part B by calling the Social Security Administration at (800) 772-1213 or by visiting www.ssa.gov (the Social Security Administration website) or www.medicare.gov. The Medicare website contains a comprehensive list of covered services, including a preventive care checklist that you can take to your health-care provider to find out which services are right for you.
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