Initial enrollment period (IEP) is a 7-month period during which an individual may enroll into Medicare Part B program that usually begins 3 months before the month in which the individual turns age 65, and ends 3 months after that after the birthday month.

If a person enrolls in Medicare after the Initial Enrollment Period ends, the person may have to pay a late enrollment penalty.

General Enrollment period runs from January 1 through March 31 of each year. The individuals who did not sign up for Medicare Part B when they were first eligible, may sign up during this enrollment period. However, the cost of Medicare Part B goes up 10% for each full 12-month period that the individual could have had Medicare Part B but didn’t. The enrollee will have to pay this penalty each time they pay premiums, for as long as they have Part B (lifetime penalty). In addition, the penalty increases the longer an individual goes without Part B coverage.

Special enrollment period (SEP) is available to individuals who are eligible for Medicare Part B based on their age, but who waited to enroll because they had a group health plan through their own or their spouse’s employer. These individuals may sign up for Part B anytime while they are still covered by the group health plan, or they may sign up during the 8 months following either the termination of the group plan or employment (whichever is first).

After the annual medical insurance deductible is met, medical insurance will generally pay for 80% of the approved charges for covered expenses for the remainder of the year. There is no maximum out of pocket limit on the 20% coinsurance payable for Part B expenses.

Doctor Services — Part B covers doctor services no matter where received in the United States. Covered doctor services include surgical services, diagnostic tests and X-rays that are part of the treatment, medical supplies furnished in a doctor’s office, and services of the office nurse.

Outpatient Hospital Services — Part B covers outpatient hospital services received for diagnosis and treatment, such as care in an emergency room, outpatient clinic, or a hospital.

Home Health Visits — Medicare will pay for home health services as long as these services are recommended by the insured’s doctor and the insured is eligible. However, these services are provided on a part-time basis with limits on the number of hours per day and days per week. The services that are not fully covered by Medicare will get coverage from Medicaid.

Other Medical and Health Services — Under certain conditions or limitations, medical insurance covers other medical services and supplies. Some examples are as follows: ambulance transportation; home dialysis equipment, supplies, periodic support services, independent laboratory tests, oral surgery, outpatient physical therapy, speech pathology services, and X-rays and radiation treatments.

Prescription Drugs (limited coverage) — Only medicines that are administered in a hospital outpatient department under certain circumstances, such as injected drugs at a doctor’s office, some oral cancer drugs, or drugs that require durable medical equipment (like a nebulizer or infusion pump), are covered. Other than the examples above, insured under Part B will have to pay 100% for most prescription drugs, unless covered by Part D.

Outpatient Treatment of Mental Illness — Medicare covers outpatient treatment of an approved condition (such as depression or anxiety) in a doctor’s office or other health care provider’s office or hospital outpatient department. Generally, the enrollee pays 20% of the Medicare-approved amount (coinsurance); Part B deductible also applies. Note that inpatient mental health care is covered under Part A.

Yearly “wellness” visit — In addition to a “Welcome to Medicare” preventive visit available during the first 12 months, Medicare Part B covers annual “wellness” visit during which the insured and the provider can develop or update a personalized plan for disease prevention. There is no out-of-pocket cost for the insured for these visits if the doctor or other qualified health care provider accepts assignments. If the doctor or the health care provider performs additional tests or services during the same visit that are not covered under this preventive benefit, the insured may have to pay coinsurance, and Part B deductible may also apply.

Medical insurance under Part B of Medicare does not cover the following:

• Private duty nursing;
• Skilled nursing home care costs over 100 days per benefit period;
• Intermediate nursing home care;
• Physician charges above Medicare’s approved amount;
• Most outpatient prescription drugs;
• Care received outside the United States;
• Custodial care received in the home;
• Dental care (except dental expenses resulting from an accident only), cosmetic surgery, eyeglasses, hearing aids, orthopedic shoes, acupuncture expenses; or
• Expenses incurred due to a war or act of war.

The following are claims terminology and other key terms applicable to Medicare:

• Actual Charge — The amount a physician or supplier actually bills for a particular service or supply.
• Ambulatory Surgical Services — Care that is provided at an ambulatory center. These are surgical services performed at a center that do not require a hospital stay unlike inpatient hospital surgery.
• Approved Amount — The amount Medicare determines to be reasonable for a service that is covered under Part B of Medicare.
• Assignment — The physician or a medical supplier agrees to accept the Medicare-approved amount as full payment for the covered services.
• Carriers — Organizations that process claims that are submitted by doctors and suppliers under Medicare.
• Coinsurance — The portion of Medicare’s approved amount that the beneficiary is responsible for paying.
• Comprehensive Outpatient Rehabilitation Facility Services — Outpatient services received from a Medicare participating comprehensive outpatient rehabilitation facility.
• Deductible — The amount of expense a beneficiary must first incur before Medicare begins payment for covered services.
• Durable Medical Equipment — Medical equipment such as oxygen equipment, wheelchairs, and other medically necessary equipment that a doctor prescribes for use in the home.
• Excess Charge — The difference between the Medicare-approved amount for a service or supply and the actual charge.
• Intermediaries — Organizations that process inpatient and outpatient claims on individuals by hospitals, skilled nursing facilities, home health agencies, hospices and certain other providers of health services.
• Limiting Charge — The maximum amount a physician may charge a Medicare beneficiary for a covered service if the physician does not accept assignment.
• Nonparticipating — Doctors or suppliers who may choose whether or not to accept assignment on each individual claim.
• Outpatient Physical and Occupational Therapy and Speech Pathology Services — Medically necessary outpatient physical and occupational therapy or speech pathology services prescribed by a doctor or therapist.
• Pap Smear Screening — Provides for a pap smear to screen for cervical cancer once every 2 years.
• Partial Hospitalization for Mental Health Treatment — A program of outpatient mental health care.
• Participating Doctor or Suppliers — Doctors and suppliers who sign agreements to become Medicare-participating. For example, they have agreed in advance to accept assignment on all Medicare claims.
• Peer Review Organizations — Groups of practicing doctors and other health care professionals who are paid by the government to review the care given to Medicare patients.