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Medicare Part B
Medicare Part B includes, but is not limited to:
- Physician services
- Outpatient hospital services
- Diagnostic tests
- Physical therapy
- Limited chiropractic services
- Durable medical equipment
- Home health services.
Individuals eligible for Medicare Part B include:
- Any individual eligible for Medicare Part A, or
- An individual 65 years and older who is:
- A U.S. Resident, and
- A U.S. Citizen; or, a Non-citizen lawfully admitted for permanent residence with 5 years continuous residence.
Any individual who qualifies for free Part A is automatically eligible to enroll for Part B. For these individuals, there are no citizenship status, immigration or U.S. residency requirements.
Premiums
There is a premium cost for all individuals eligible for Medicare Part B. The premium cost is deducted from the gross benefit amount of those enrolled individuals receiving RSDI or Railroad Retirement payments. Other eligible persons can purchase Part B coverage through payment of a monthly premium.
MC, through the State Buy-In agreement, pays the Part B premiums of all Medicare recipients. The Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) programs are also available to pay for all or some of the Part B premium. How Medicare And Medi-Cal Work Together
Crossover Claims
Individuals who have both Medicare and Medi-Cal are described as having crossover benefits. In order to be paid by both Medicare and Medi-Cal, the provider must agree to accept Medicare's allowable charge as payment in full. After the annual Medicare deductible has been met, Medicare will pay the remaining charges for all Medicare Part A covered services and 80% of the costs of Part B covered services.
Medi-Cal may or may not pay the remaining charges, or a portion of the remaining charges, depending on the Schedule of Maximum Allowances (SMA) fee schedule.
Medicare is the first to pay for any service that is covered by both programs.
If the provider accepts Medi-Cal for a service, he or she may not bill the patient for more than the amount paid by Medicare plus Medi-Cal.
A Medi-Cal patient, who sees a physician or provider who chooses not to accept Medi-Cal, should be advised by that provider, before services are rendered, that:
- He/she is not being accepted as a Medi-Cal patient, or that the provider may not wish to bill Medi-Cal for a particular service.
- The patient will have to pay the additional amount not covered by Medicare.
Medicare Deductibles
Both Medicare Part A and Part B have deductibles which are paid by the patient or Medi-Cal.
- For the Medi-Cal beneficiaries with no share of cost, or a Qualified Medicare Beneficiary (QMB), these deductibles are paid by Medi-Cal.
- A Medi-Cal beneficiary who is responsible for paying the Medicare deductible can have this expense included in meeting the Medi-Cal share of cost, just as other medical expenses do.
Other Services
Medi-Cal pays the cost of some services which are not covered by Medicare (e.g., certain outpatient prescriptions, custodial level nursing care, glasses, some dental services, hearing aids, etc.).
Medicare Part B-Immunosuppressive Drug Benefit (ID)
Beginning January 1, 2023, individuals who lost Medicare coverage after 36 months of receiving a successful Kidney Transplant due to End Stage Renal Disease (ESRD) may receive a limited Part B benefit that covers immunosuppressive medications only. This applies to individuals who have exceeded their 36-month ESRD Medicare coverage, are not eligible for Medicare and do not qualify for or are enrolled in another health plan.
The individual must not be enrolled in other health coverage this includes group or individual plans, TRICARE, National Health plans, VA coverage, Medi-Cal or CHIP health coverage that includes immunosuppressive drug coverage.
Medicare Part B-ID Outreach
The Department of Health Care Services (DHCS) will send contact letters to eligible individuals who do not have full scope Medi-Cal coverage and have been identified by the Social Security Administration as qualifying for Medicare Part B-ID. The outreach notice will guide and instruct this population to apply for Medi-Cal via the county office, Covered California and various methods.
Medi-Cal Application
DHCS will send a list of individuals to the Social Services Agency who may have applied for MC. If the individual does not submit an MC application, the county is not required to take further action.
If the MC application is received, or if Medicare Part B-ID individuals are identified during annual renewal or a CIC:
- Screen and determine applicant/beneficiary eligibility for MAGI MC and Non-MAGI programs.
For individuals not eligible for full scope MC, determine eligibility for Medicare Savings Programs (MSP). When determining for MSP, treat the Medicare Part B-ID individual as eligible for Medicare.
System Functionality
The SAWS system will fail individuals for QMB and SLMB when they are not enrolled in Medicare Part A. To grant QMB or SLMB for individuals receiving only Medicare Part B Immunosuppressive Drug Benefit, workers will need to complete an override.
To identify potential Medicare Part B-ID recipients, the individual may have documentation from Social Security Administration identifying them as potentially or classified as eligible. Individuals already classified as eligible will have a Buy-in Eligibility Code "J" in the "BUY-IN-ELIG-CD" field on the MEDS INQB, or an "I" in the "Basis" field on the Medicare Part B line of the MEDS INQB screen, with or without the "J" code present.
Medicare Part-B ID premium
The Medicare Part B-ID premium is an allowable income deduction for individuals paying the premium. Beginning in 2022, federal law will determine a monthly premium rate in September for the succeeding calendar year for individuals enrolled in the Part B-ID benefit. The premium is equal to 15 percent of the monthly actuarial rate for enrollees age 65 and over for that succeeding calendar year.
For 2023, the Part B-ID premium is $97.10.
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