Original Medicare coverage in New Jersey consists of two main parts: Part A and Part B. Part B is your medical insurance, whilst Part A is hospital insurance. Part B has the most comprehensive coverage of Original Medicare and it provides outpatient, medical, and doctor services.
Part B Coverage In New Jersey
Part B covers services that are related to outpatient care. Therefore, this coverage includes:
- doctor visits: if you go to a doctor or specialist, this service will be covered under Part B
- outpatient care
- preventive care: vaccines like flu shots, annual cancer screenings, lab work, etc.
- home health care
- durable medical equipment: wheelchairs, crutches, etc.
- diagnostic tests: x-rays, blood work
- mental health care
- ambulance transportation
Overall, Part B provides coverage for all medical services that are considered necessary. If your doctor deems it as a medical necessity, that’s going to fall under your Part B coverage.
Medicare Part B Costs Per Beneficiary
Part B works on an 80:20 scale, which means that once you enroll in Part B Medicare covers 80% of services. That leaves beneficiaries responsible for 20%, but this 20% can be easily covered by enrolling in Medicare Supplement plans. Medicare Supplement plans are standardized insurance plans from letters A to N which help cap out the costs left by Original Medicare. This 20% of the costs may not seem large, but you are responsible for 20% of all outpatient services and there is no limit on this 20% which means you can be left out with large out-of-pocket costs. You are eligible for supplemental coverage when your Part B becomes effective. With a combination of Original Medicare and supplemental plan, beneficiaries can get full coverage benefits.
Additionally, Medicare Part B costs consist of:
- monthly premium: in 2023, the premium cost is 164.90$ (but you may pay a higher premium cost due to higher income- this is called Income Related Monthly Adjustment Amount = this amount is calculated based on the tax return from 2 years ago)
- Part B deductible: 226$ per year in 2023
- remaining 20% of the cost: coinsurance or copayment
- possible excess charges: up to 15% of the charge if the doctor doesn’t accept Medicare Assignment
Medicare Part B Excess Charges In New Jersey
Medicare Part B excess charges in New Jersey, are not that common but can happen if you don’t have a supplemental plan like plan G or F which cover those charges. But, even if you have some other comprehensive plan, like plan L, which doesn’t cover Part B excess charges you don’t have to worry because this is still pretty rare.
Part B excess charges can happen if you go to a doctor that doesn’t accept Medicare Assignment so it won’t charge you by Medicare-approved amount. They can charge you up to 15% above the Medicare-approved amount for provided service. However, this is a pretty rare occasion because most healthcare providers accept Medicare Assignment. Also, you can easily avoid excess charges by checking the list of providers which accept Medicare coverage.
Medicare Part B Therapy Cap In 2023
Since Medicare Part B covers outpatient therapy, which includes physical therapy, speech-language pathology, and occupational therapy. There was a therapy cap on how much will Original Medicare cover for outpatient services. But, in 2018, this cap was removed. Instead, the cap was switched to the Medicare therapy threshold or KX modifier which helps providers to indicate the medical necessity of the provided services that exceed the threshold amount.
There is one amount for physical therapy and speech-language services combined, and one amount for occupational therapy services. This amount is subject to change and it is indexed annually by Medicare Economic Index.
In 2023, the KX modifier threshold amount is 2230$ for PT and PSL services combined and OT services. Related to KX modified threshold there is also a medical review process threshold which is 3000$ from 2018 to 2028.
Medicare Part B Eligibility
You are automatically eligible for Medicare Part B when you turn 65 years or if you are younger but are receiving Social Security Disability benefits for at least 24 months in a row or have ALS or ESRD. Also, to qualify you must be a U.S. citizen or a legally admitted citizen who has lived in the States for a minimum of five years.
How To Apply For Medicare Part B In New Jersey
To apply for Medicare Part B you can do it online on the official government page. If you are retired or self-employed the best time to enroll in Part B is during the Initial Enrollment Period. IEP is different for every individual because it begins when you are first eligible for Medicare coverage. This is a 7-month open enrollment window that starts 3 months before your 65th birthday, during your birthday month, and 3 months after you are 65.
Be aware when you enroll during this period because the effective date of Part B coverage depends on the month you choose to enroll. If you enroll in three month period before your 65 birthday your coverage will start the first day of the month when you are supposed to turn 65.
However, if you choose to do it in your birthday month, your Part B effective date will be 1 month after you sign up, and if you choose to do it 1 month later your coverage will start 2 months after. If you choose to enroll 2 or 3 months after your 65th birthday, then your coverage will start 3 months after you signed up.
If you don’t apply for Medicare Part B during IEP, and you have hadn’t creditable coverage before, you will have to pay a penalty for late enrollment if you choose to do it later.
However, if you are 65 but currently employed and have group health coverage, you can delay your Part B enrollment without a penalty. This is the case if you work in a company that has more than 20 employees because your group health insurance coverage is the primary source and Medicare second source of coverage. When you retired, and your IEP has passed, you can apply under 8 months after losing active employer benefits during the Part B special enrollment period by submitting the Part B enrollment form and employer form to Social Security.
For more about Medicare Part B in New Jersey, read our Questions & Answers blog.
Craig W. Hansen is an insurance professional and co-founder of William & Michael Advisor Group LLC and Jersey Insurance Solutions. Craig has served his clients in many facets of the insurance industry, always with the same goal: excellence in service while building solid, long-term, lasting relationships. With over a decade of experience in the insurance benefits industry, Craig’s clients know they can call on him anytime and receive platinum service with a smile.
