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Medicare: Part B

Medicare Part B provides benefits that supplement the coverage provided by Part A. It makes voluntary supplementary medical insurance (SMI) available to most individuals age 65 or over and to disabled individuals under age 65 who are entitled to hospital insurance under Medicare Part A. The SMI program is financed in part by beneficiaries who pay a monthly premium and a yearly deductible. The program also receives federal funding. As of 2005, new enrollees in Medicare Part B are eligible for a one-time initial wellness physical examination within six months of enrollment, as part of enhanced preventive service benefits under Part B.

SMI is administered by insurance companies, referred to as carriers, which have entered into contracts with CMMS to perform designated functions as agents of CMMS. Those functions include receiving, disbursing, and accounting for funds in making payments for covered services; providing an opportunity for a fair hearing if CMMS denies an enrollee’s request for payment; and assisting enrollees in locating physicians participating in the Medicare Part B program.

Not every physician provides services covered by Medicare. Physicians must agree to participate in the Medicare program, promise to accept the Medicare approved charge as payment in full, and then submit only charges that are reasonable and necessary for treating the patient. 42 U.S.C.A section 1395u. Federal law prohibits physicians from charging more than 115% of Medicare’s approved charge. Medicare will reimburse the beneficiary 80% of Medicare’s approved charge, and the beneficiary is responsible for the remainder. 42 U.S.C.A. section 1395w-4(g)(2)(C). Fines and penalties apply to physicians who charge above the 115% cap, including exclusion from the Medicare program and monetary penalties of up to $2,000 per violation.

Persons entitled to Part A benefits are enrolled automatically in Part B, unless they indicate that they do not want to participate in Part B. Persons who do not apply for Social Security benefits and are therefore not automatically enrolled in Medicare can apply at the local Social Security Administration office or by mail. Generally, individuals can enroll in Medicare Part B during an initial seven-month enrollment period that begins 3 months before their 65th birthday and ends 3 months after it. Individuals who miss their initial enrollment period may only enroll during a general enrollment period, which lasts from January through March of each year. Coverage then becomes effective on July 1st of that year.

Individuals who enroll during the first three months of the initial enrollment period are eligible for Part B entitlement beginning in the first month of their eligibility to enroll. If an individual enrolls during the fourth month of the initial enrollment period, entitlement begins the following month. Individuals who enroll during the fifth month of the initial enrollment period are eligible for Part B entitlement beginning with the second month after the month of enrollment. For individuals who enroll in either of the last two months of the initial enrollment period, entitlement begins with the third month after the month of enrollment.

Part B beneficiaries may terminate their enrollment at any time by giving CMMS written notice that they no longer wish to participate in the SMI program. Entitlement to benefits under the program terminates at the end of the month after the month in which the individual files the disenrollment request. Entitlement also terminates upon death, termination of entitlement to Medicare Part A benefits, or nonpayment of premiums. Termination upon death ends SMI entitlement on the last day of the month in which the individual dies.

Part B covers the services of physicians and other health practitioners; supplies furnished incidental to physicians’ services; outpatient hospital services; rural health clinic services; comprehensive outpatient rehabilitation facility services; physical and oc-cupational therapy services; speech pathology services; prosthetic devices and durable medical equipment; ambulance services; X-ray treatment; and diagnostic and other laboratory tests. 42 U.S.C.A. section 1395k(a); 42 U.S.C.A. sections 1395x et seq.

The Part B program is not comprehensive. Excluded items include dentures and other dental care; most outpatient drugs, except where the drugs are physician-administered during covered treatment; routine physical examinations; hearing aids; orthopedic shoes; and eyeglasses and eye examinations. 42 U.S.C.A. section 1395y(a). Medicare covers limited preventive care services, such as pap smears, pelvic exams, mammograms, colorectal cancer screening, prostate cancer screening, bone mass measurement tests, and flu, pneumococcal, and hepatitis B shots. It also covers diabetes glucose monitoring and diabetes education.

Inside Medicare: Part B