Medicare Part B Benefits--Essential Tips to Understanding Medicare part B Medical

Somewhere in between, I hope and closer to the pussy cat than the tiger. Inspite of the vast amount of information about Medicare, many seniors as well as concerned family members remain confused as to the nature of their benefits. I'd like to start by first mentioning that Original Medicare is the Medicare program managed by the Federal Government. As such, it is in Original Medicare that you can choose to see any doctor, hospital or any other medical professonal enrolled in the Medicare program anywhere in the United States. So, Original Medicare coverage is available nationwide.

Although I will mostly be talking about Medicare Part B benefits, Orginal Medicare consists of,

• Part A--inpatient hospital coverage
• Part B--doctors services, outpatient coverage, medical equipement and supplies

The Medicare program itself also consists of two additional "modules", and these are,

• Part D--Medicare prescription drug coverage
• Part C--Medicare Advantage Plans, which are alternative means of having your Medicare Part A, B, and D benefits managed available through private insurance companies.

Although I may touch on all aspects of Medicare coverage, I am mostly concerned here with the Part B benefits, or medical benefits, of Original Medicare. so, is Medicare really an incomprehensible bureaucratic nightmare? To my way of thinking, the answer as it concerns Medicare beneficiaries is generally, "no." In my opinion, much of the confusion surrounding the program has been contributed by the many private insurance companies seeking to profit from the somewhat deregulated features, meaning the Advantage and Part D programs. My advice would be to stick to careful reading of the official CMS (Centers for Medicare and Medicaid Services) publications, such as the Medicare and You Handbook.

But enough general talk. Let's find out more about the Part B medical benefits.

One of the first things to understand is that in order to receive Part B benefits, all beneficiaries must pay a Part B premium. The only exception to that would be if your state of residence is subsidizing your premium due to limited income.

Part B is is the Medicare plan, or coverage, that helps pay for doctor services, outpatient care, and medical supplies. I will cover the benefits that Medicare typically pays for under Part B in more detail, but it is important to understand that without Part B coverage, Medicare has no way to pay for most doctor services provided as a hospital inpatient. Many people make the mistake of thinking that Part A will cover doctor care received as an inpatient or during an outpatient stay, but that is not the case. Doctor services, whether received as an inpatient, outpatient, or clinic setting can only be paid for by Part B.

So what are the typical benefits that Part B pays for? Keep in mind that Part B pays for services if they are medically necessary. Medical neccessity is a key factor in understanding Medicare's coverage determinations. It is also important to understand that Medicare does not pre-authorize coverage. This is in clear contrast to the policies of private insurance companies who do, generally, require pre-authorizaton before receiving care. And Medicare makes its coverage determinations at the time providers send a claim to Medicare. Having said that, let's take a look specific categories and services that Part B typically covers:

• Doctors' services and second and third medical and surgical opinions.
• Outpatient doctor and hospital servives.
• Ambulatory surgery center facility fees.
• Ambulance services.
• Emergency room services.
• Blood
• Chiropractic manual manipulations of the spine.
• Clinical lab services such as, urinalysis, blood tests, and lipid panels.
• Imaging such as, x-rays, MRIs, PET scans, CT scans, ultra sounds.
• Implantable defibrillator
• Diabetes screeings
• Medical supplies, such as wheel chairs, diabetic test strips, walkers, oxygen.
• Eye exams for people with diabetes.
• One pair of eye glasses following cataract surgery.
• Flu shots
• Hepatitis B shots.
• Pneumonia vaccine shot.
• Podiatry services.
• Hearing and balance exams.
• Kidney dialysis services and supplies.
• Medical nutrition therapy.
• Outpatient mental health care.
• Physical therapy, speech language therapy, and occupational therapy.
• Prescription drugs delivered as part of the treatment received in a doctor's office or outpatient setting.
• Surgical dressings.
• Transplants and immunosuppressive drugs.

This list by no means covers each individual service that Part B covers, but it helps you understand the typical range of services that Part B normally helps pay for.

Now, although Medicare Part B benefits require that services be medically necessary, Medicare does cover a range of preventive screening exams, and those will be covered in the next section.

Medicare Part B benefits do not typically cover routine services. Medicare guidelines specifically state the Medicare Part B does not cover routine exams or yearly physical exams. However, Medicare does help pay for preventive screening services, and what Medicare covers in this regard is extensive. However, in order for Medicare to pay for the screening exams it is important to remember that Medicare is a fee for service health insurance program, and fee for service Medicare requires that the doctor bill specifically for each service rendered. Thus, a doctor cannot perform a screening mammography but bill for an office visit. The doctor must bill for the exact service performed.

Under the Medicare preventive service benefits, the following procedures are paid for:

• abdominal aortic aneurysm screenings
• bone mass measurement
• cardiovascular screenings
• colorectal cancer screenings
• fecal occult bolood tests
• flexible sigmoidoscopies
• colonoscopies
• barium enemas
• diabetes screenings
• diabetes self-management training
• EKG screenings
• flue shots
• glaucoma tests
• hepatitis B shots
• mamograms
• medical nutrition therapy services
• pap tests and pelvic exams
• the one-time "welcome to Medicare " physical exam
• pneumococcal shots
• prostate cancer screenings
• smoking cessation counseling

I'll mention again that the above services are intended to be preventive screenings, and that they are a special class of routine services that Medicare covers.  You'll recall that earlier I stated that Medicare Part B does not cover routine exams, and that is true with the exception of this special class of preventive benefits.  Since the services are in class of their own, they also have their own billing codes, and for that reason it is important that when you have, for example, a preventive screening cervical exam or preventive screening PSA test, that the doctor bill Medicare specifically for the preventive screenings as opposed to diagnostic exams for the same services.  For billing purposes, there is a difference between a PSA test given for diagnostic reasons and PSA test given as a preventive screening, and it is important that the billing to Medicare reflect the correct service.