Original Medicare: Doctor, Home Health, and Preventive Care

Medicare Part B helps pay for doctor bills, some home health care, certain preventive services, outpatient hospital care, medical equipment and supplies, laboratory services, x-rays, physical therapy, mental health services, ambulance services, and blood. It does not pay all of these costs. You must pay some of these costs too.

What You Pay Under Medicare Part B

• Premium: A premium is the monthly payment for health insurance. The Medicare Part B premium is $58.70 in 2003. The premium can change every year. If you are receiving Social Security or Railroad Retirement benefits, the premium is taken out of your monthly checks. If not, Medicare sends you a bill every three months.
• Deductible: A deductible is the amount you must pay for your health care before Medicare starts to pay. The Medicare Part B deductible is $100 in 2003.
• Coinsurance: Coinsurance is the percent you must pay for your health care. Usually it is 20 percent of the Medicare-approved amount for most doctor bills, other health care services, and medical equipment. The Medicare-approved amount is the amount Medicare decides is a reasonable payment for a medical service.

FYI: While signing up for Medicare Part B is your choice, it's important to know:

• If you don't sign up for Part B when you first go on Medicare, you may have to pay more for the Part B premium when you do sign up.
• Once you sign up for Part B at 65 or older, you have six months to buy any Medicare Supplemental (Medigap) Insurance policy you choose, regardless of your health. This is called your open enrollment period. You only have this period once in your life. After this six month period, you may not be able to buy the Medigap policy you want.

Talk to Medicare and your State Health Insurance Assistance Program (SHIP) before making a final decision about when to sign up for Medicare Part B.

Here is an example of what you might pay for a doctor visit...

In March, Joan saw her doctor for the first time that year. The bill for the doctor visit was $100, the Medicare approved amount. Joan paid this $100 as her yearly Part B deductible.

In June, Joan goes to her doctor for a follow-up visit. The bill for this follow-up visit is also $100. Since Joan has already paid her deductible, Medicare will now pay its share, $80 (80 percent of $100), and Joan will pay her share, $20 (20 percent of $100).

In this example, Joan's doctor "accepts assignment" with Medicare. This means that the doctor agrees to not charge more than the Medicare-approved amount.

What Medicare Part B Covers and What You Pay

Here is a list of the doctor, medical and preventive services covered by Medicare Part B and what you need to pay.

Ambulance Services

You pay: 20 percent of the approved amount when an ambulance is needed to take you to or from a hospital or skilled nursing home.

Blood

You pay: 20 percent of the approved amount after you pay for the first three pints of blood.

Doctors

You pay: 20 percent of the approved amount for doctors' services, after you pay the yearly Part B deductible. Routine check-ups are not covered.

Home Health Care

You pay: Nothing for approved services such as part-time skilled nursing care; doctors; physical, occupational, and speech therapy; home care, home health aides; ambulance services; medical social services; and other supplies and services.
You pay: 20 percent for medical equipment such as wheelchairs, walkers, and oxygen.

Laboratory Tests

You pay: Nothing for approved services.

Medical Equipment

You pay: 20 percent of the approved amount for most medical equipment after you pay the yearly Part B deductible. You must buy the equipment from suppliers approved by Medicare.

Mental HealthServices

You pay: 50 percent of the approved amount for most outpatient mental health services.

Outpatient Hospital Care

You pay: a part of outpatient care. Amount will vary according to the service. The most you will pay is the Medicare Part A hospital deductible ($840 in 2003).

X-rays

You pay: 20 percent of the approved amount for X-rays needed to make a medical diagnosis.

Preventive Services

Bone density measurement: for people at risk for losing bone mass.

You pay: 20 percent of the approved amount, after you pay the yearly Part B deductible.

Colorectal cancer screening: for people 50+.

• Fecal Occult Blood Test: Once every 12 months. You pay nothing.
• Flexible Sigmoidoscopy: Once every 48 months. You pay 20 percent of the approved amount, after you pay the yearly Part B deductible.
  You pay: 25 percent if done in a surgical center or hospital outpatient department.
• Colonoscopy: Usually once every 10 years.
  You pay: 20 percent of the approved amount, after you pay the Part B deductible.
  You pay: 25 percent if done in a surgical center or hospital outpatient department.
• Barium Enema: Doctor can decide to use instead of sigmoidoscopy or colonoscopy.
  You pay: 20 percent of the approved amount, after you pay the yearly Part B deductible.

Diabetes care: for supplies and self-care training.

You pay: 20 percent of the approved amount, after you pay the yearly Part B deductible.

Glaucoma screening: for people at high risk for glaucoma. Screening must be done by eye doctor.

You pay: 20 percent of the approved amount, after you pay the yearly Part B deductible.

Mammograms: for women 40+ once every twelve months. Women between 35 and 39 can get one baseline mammogram.
You pay: 20 percent of the approved amount. The yearly Part B deductible does not apply.

Pap smears, Pelvic and Clinical Breast Exams: for all women every 24 months.

• Pap Smear Test: You pay nothing.
• Pap Smear Collection, Pelvic and Breast Exams: You pay 20 percent of the approved amount. The yearly Part B deductible does not apply.

Prostate cancer screening: for men 50+ every 12 months.

• Digital rectal exam: You pay 20 percent of the approved amount, after you pay the yearly Part B deductible.
• PSA Test: You pay nothing. The yearly Part B deductible does not apply.

Shots: for all people with Medicare.

• Flu Shot: once a year. You pay nothing.
• Pneumonia: you may only need once. Check with your doctor. You pay nothing.
• Hepatitis B: for those at risk for hepatitis.
  You pay: 20 percent of the approved amount, after you pay the yearly Part B deductible.

Care at Home

Medicare Part A and Part B both help pay for home health care. Home health care is skilled nursing and other kinds of health care services that you get in your home to treat an illness or injury. (Medicare doesn't pay for care to help with activities of daily living such as bathing, dressing, or using the toilet.)

You must meet four conditions for Medicare to help pay for your home health care:

1. Your doctor must order medical care for you in your home and make a plan for that care.
2. You must need help from a skilled nurse or a physical, occupational, or speech therapist on a part-time basis. Medicare does not pay for these services round-the-clock (24 hours).
3. You must be homebound. This means it is very hard for you to leave your home because of your illness or injury.
4. You must get your care from a home health care agency approved by Medicare.

Medicare pays for your home care for as long as you meet these conditions. Your doctor and home health care agency will review your plan of care at least every 60 days.

What Medicare Pays

Medicare will pay for the following as part of your home health care:

• part-time skilled nursing care
• home health aides
• physical, occupational, or speech therapists
• medical social services or counseling to help you cope with your illness or injury
• medical equipment and supplies

Medicare Part B doesn't cover

• most outpatient prescription drugs
• routine check-ups
• most dental care
• hearing aids
• routine eye care
• routine foot care
• someone to help you bathe, dress, go to the bathroom, or eat meals at home and for an long period of time
• most chiropractic services
• acupuncture
• health care when you travel outside the United States
• cosmetic (plastic) surgery

AARP Resources

Medicare Prescription Drug Campaign
Keep up-to-date on AARP's campaign to include a prescription drug benefit in Medicare.

Medicare Savings Programs
Information about programs that help people with low-incomes pay for some of their Medicare costs.

Understanding Medicare, Medigap, and Medicaid
AARP explains how these programs work.

State-by-State, Plan-by-Plan List of Pharmacy Assistance Programs
Prescription discount programs offered by states, drug makers, discount cards and discount pharmacies.

Additional Resources

Prescription Drug Assistance Programs
Lists the programs that offer free or discounted prescription drugs and the Medicare and Medigap plans in your area that offer prescription drugs.

State Health Insurance Assistance Program (SHIP)
How to contact your State Health Insurance Assistance Program (SHIP), an important Medicare partner. Free one-on-one health insurance counseling to people with Medicare

National Association of Home Care
Information about Medicare coverage for home health care