On expenses Incurred for:

Medicare Covers

You pay $240 Annual Deductible PLUS

Medical Expenses – Physician’s services for inpatient and outpatient medical/surgical services; physical/speech therapy, diagnostic tests.

Most confinement 80% of approved amount

20% of approved amount

Clinical Laboratory Services Blood tests, urinalysis

Generally, 100% of approved amount

Nothing for services

Home Health Care – Part-time or intermittent skilled care, home health aide services, durable medical supplies and other services.

100% of approved amount; 80% of approved amount for durable medical equipment

Nothing for services; 20% of approved amount for durable medical equipment

Outpatient Hospital – Treatment Hospital services for the diagnosis or treatment of an illness or injury.

Medicare payment to hospital, based on outpatient procedure payment rates

Coinsurance based on outpatient procedure payment rates

Blood

After first 3 pints of blood, 80% of approved amount

First 3 pints plus 20% of approved amount for additional pints

Tax Filing Status

Individual

Joint

Married but Separate

Premium is

If Your 2022 Annual Income Was*

$174.70

$103,000 or less

$206,000 or less

$103,000 or less

$244.60

$103,001 – $129,000

$206,001 – $258,000

$349.40

$129,001 – $161,000

$258,001 – $322,000

$454.20

$161,001 – $193,000

$322,001 – $386,000

$559.00

$193,001 – $499,999

$386,001 – $749,999

$103,001 – $396,999

$594.00

Above $500,000

Above $750,000

Above $397,000

Part B Covered Services

Details

Bone Density Measurement

One every 24 months

Cardiac Rehabilitation

Exercise, education and counseling

Cardiovascular Screenings

One every 5 years

Chiropractic Services

Limited

Clinical Laboratory Services

Certain screening tests

Clinical Research Studies

Tests to determine safety of new procedures

Colorectal Cancer Screenings

• Fecal Occult Blood Test

• Sigmoidoscopy

Colonoscopy / Barium Enema

One every 12 months

One every 4 or 10 years depending upon risk

One every 4 or 10 years depending upon risk

One every 4 years

Defibrillator

Implantable automatic

Diabetes Screenings

Up to two each year

Diabetes Self-Management Training

With doctor’s order

Diabetes Supplies

Includes monitors, test strips and lancets Insulin is covered if using an external pump

Doctor Services

Includes outpatient and some hospital inpatient

Durable Medical Equipment

Oxygen equipment and supplies, wheelchairs, walkers, and hospital beds

EKG Screening

Initial Medicare exam and as a diagnostic test

Emergency Room Services

Doctor’s services

Eye Glasses

One pair after cataract surgery

Health Center Services

At federally approved community-based organizations

Flu Shots

Once per flu season

Foot Exams

If you have diabetes

Glaucoma Tests

One every 12 months

Hearing and Balance Exams

Does not include hearing aids

Hepatitis B Shots

For people at high or medium risk

HIV Screening

One every 12 months

Home Health Services

Part-time skilled nursing care or physical therapy, speech-language pathology, or occupational therapy

Kidney Dialysis

Services and supplies

Mammograms

One every 12 months

Medical Nutrition Therapy Services

If you have diabetes or kidney disease or kidney transplant in the last 36 months

Mental Health Care

Outpatient to help with conditions like depression

Non-doctor Services

Physician assistants, nurse practitioners, social workers, physical therapists and psychologists

Occupational Therapy

After an illness or accident to help you return to work

Outpatient Medical and Surgical Services and Supplies

For procedures like X-rays, a cast or stitches

Pap Tests, Pelvic and Breast Exams

Checks for cervical, vaginal and breast cancer

Physical Exams

One per year – must be 12 months apart

Physical Therapy

For injuries and diseases

Pneumococcal Shot

Helps prevent pneumonia

Prescription Drugs – Limited

Injections at a doctor’s office, certain oral cancer drugs, drugs used with some types of durable medical equipment, and some outpatient drugs at a hospital

Prostate Cancer Screenings

Once every 12 months

Prosthetic/Orthotic Items

Limbs and braces; includes ostomy supplies

Pulmonary Rehabilitation

If you have moderate to severe COPD

Rural Health Clinic Services

Includes many outpatient primary care services

Second Surgical Opinions

If surgery is not an emergency

Smoking Cessation

If you’re diagnosed with an illness caused or complicated by smoking

Speech-Language Pathology Services

Treatment to regain and strengthen speech and language skills and swallowing skills

Surgical Dressing Services

For treatment of a surgical wound

Telehealth

Provided in an approved rural facility

Tests

X-rays, MRIs, CT scans, EKGs and some other diagnostic tests

Transplants and Immunosuppressive Drugs

Pays for doctor services in a Medicare-certified facility. Immunosuppressive drugs covered if Medicare or employer group plan paid for the transplant and you were entitled for Part A at the time of transplant

Urgently-Needed Care

For sudden illness or injury that isn’t an emergency