Thursday, July 12, 2012

what is Medicare part B and who is covered


Part B – Medical Insurance




Some of the services that Part B, medical insurance, helps pay for include

: Medically necessary services furnished by physicians in a variety of medical settings, including but not limited to:
o The physician’s office;
o An inpatient or outpatient hospital setting; and

o Ambulatory Surgical Centers; Home health care for individuals who do not have Part A; Ambulance services; Clinical laboratory and diagnostic services; Surgical supplies; Durable medical equipment, prosthetics, orthotics, and supplies; Hospital outpatient services

; and Services furnished by practitioners with limited licensing such as:
o Audiologists;
o Certified nurse midwives;
o Certified registered nurse anesthetists;
o Clinical nurse specialists;
o Clinical psychologists;
o Clinical social workers;
o Independently practicing occupational therapists;
o Independently practicing physical therapists;
o Nurse practitioners; and
o Physician assistants.


Eligibility Guidelines

All individuals who are eligible for premium-free Part A are eligible to enroll in Part B. Since Part B is a voluntary program that requires the payment of a monthly premium, those individuals who do not want coverage may refuse enrollment. An individual age 65 years or over who is not eligible for premium-free Part A must be a U.S. resident and either a citizen or an alien lawfully admitted for permanent residence who has resided in the U.S. continuously for the five-year period immediately preceding the month the

Part B enrollment application is filed. Individuals who refused Part B and those whose Part B coverage terminated may enroll or re-enroll in Part B only during prescribed enrollment periods

For Medicare part A eligibility guidelines see the previous post.

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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download