Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition.
If you’re in a Medicare Advantage Plan or other Medicare plan, you may have different rules, but your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in certain settings or for patients with certain conditions.
Part B covers two types of services:
- Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.
You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.
Part B covers things like:
- Clinical research
- Ambulance services
- Durable medical equipment (DME)
- Mental health
- Partial hospitalization
- Getting a second opinion before surgery
- Limited outpatient prescription drugs
Two ways to find out if Medicare covers what you need:
Talk to your doctor or other health care provider about why you need certain services or supplies, and ask if Medicare will cover them. If you need something that’s usually covered and your provider thinks that Medicare won’t cover it in your situation, you’ll have to read and sign a notice saying that you may have to pay for the item, service, or supply.
Medicare coverage is based on three main factors
- Federal and state laws.
- National coverage decisions made by Medicare about whether something is covered.
- Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
Part B costs if you have Original Medicare
- Part B annual deductible: You pay $147 per year for your Part B deductible in 2013 and 2014.
- Clinical laboratory services: You pay $0 for Medicare-approved services.
- Home health services:
- $0 for home health care services.
- 20% of the Medicare-approved amount for durable medical equipment.
- Medical and other services: You pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy, and durable medical equipment.
In 2013 and 2014, there may be limits on physical therapy, occupational therapy, and speech language pathology services. If so, there may be exceptions to these limits.
Learn more about Medicare at www.medicare.gov/index.html.