What Are The Medicare Dual Residency Requirements
You must enroll in Medicare only in the state in which you primarily reside. Your primary residence is where you live most of the time. Its where you hold your drivers license, register to vote, and file taxes.
Yet, your coverage will work as long as you visit practitioners who accept Medicare assignment. Fortunately, this list includes almost all practitioners in the United States.
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Original Medicare can be used in all 50 states, as well as in the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the Virgin Islands. The same isnt true for Medicare Advantage plans. These plans have defined service areas and may not cover out-of-state care, with the exception of emergency and urgent care situations.
Are The Costs Of Doctor Visits Different For Medicare Beneficiaries
What you pay will vary depending on whether your doctor is a Medicare participating provider, meaning they accept Medicares payment as payment in full. KFF found that 96% of Original Medicare doctors were participating providers, while 4% did not participate. Non-participating providers can charge patients up to 115% of Medicares rates, minus the amount Medicare pays. Medigap Plans F and G can cover these additional amounts, which are known as excess charges.
A small number of providers dont bill Medicare at all. Just over 26,000 providers have opted out of Medicare as of March 2020, which means they cant see Medicare beneficiaries without entering into a private contract where the patient agrees to pay full price. More specialists opt out of Medicare than other types of providers.
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Do I Need Cards Other Than My Medicare Card
You may have other insurance cards in addition to cards for Original Medicare , Medicare Advantage and Medigap. Insurers will usually send you a new card each year, although your Original Medicare card will not change. Its a good idea to make sure your providers have up-to-date insurance information for you so there arent delays in billing for medical care.
Although it all adds up to a lot to carry, its probably best to keep your Original Medicare, Medicare Advantage, Medigap, and Part D cards with you at all times. Because theres less of a chance you might spontaneously need other insurance cards like a private dental plan or long-term care insurance policy so you can probably store those in a safe place at home.
If you are struggling to choose Medicare coverage that includes your health care providers, free help is available from State Health Insurance Assistance Programs in each state.
Josh Schultz has a strong background in Medicare and the Affordable Care Act. He coordinated a Medicare ombudsman contract at the Medicare Rights Center in New York City, and represented clients in extensive Medicare claims and appeals.
In addition to advocacy work, Josh helped implement federal and state health insurance exchanges at the technology firm hCentive. He also has held consulting roles, including as an associate at Sachs Policy Group, where he worked with insurer, hospital and technology clients on Medicare and Medicaid issues.
Tips For Selecting Plans That Meet Your Needs
- Assess your current and potential healthcare needs. Are there doctors, facilities, or medications that you can’t compromise on for your care? This may impact your policy choice, particularly when deciding between original Medicare and Medicare Advantage.
- Consider your income. If you have a fixed or limited income, paying monthly premiums may be difficult. However, if you may need care that only Medicare Advantage would cover, this might be a good option to save costs in the long run.
- Look for cost savings programs. You may qualify for certain programs to help with your costs, including Medicaid and Extra Help.
- Find the right plan. Use Medicares plan finder tool to compare available Medicare Advantage plans in your area. You can search by prescription drugs you need, as well as covered providers and services.
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Should I Take Medicare Part B
You should take Medicare Part A when you are eligible. However, some people may not want to apply for Medicare Part B when they become eligible.
You can delay enrollment in Medicare Part B without penalty if you fit one of the following categories.
Employer group health plans may cover items normally not covered by Medicare Part B. If so, and you meet one of the categories above or below, then you may not need to enroll in Medicare Part B and pay the monthly premium.
If you are:
- a spouse of an active worker
- a disabled, active worker
- a disabled spouse of an active worker
and choose coverage under the employer group health plan, you can refuse Medicare Part B during the automatic or initial enrollment period. You wait to sign up for Medicare Part B during the special enrollment period, an eight month period that begins the month the group health coverage ends or the month employment ends, whichever comes first.
You will not be enrolling late, so you will not have any penalty.
If you choose coverage under the employer group health plan and are still working, Medicare will be the “secondary payer,” which means the employer plan pays first.
If the employer group health plan does not pay all the patient’s expenses, Medicare may pay the entire balance, a portion, or nothing. An employer group health plan must be primary or nothing.
Choosing The Private Insurance Option
If none of these situations apply to you and you want to use private insurance instead, its important to understand that there is only a seven-month window in which you can apply for Medicare benefits, according to Medicare.gov.
This period typically begins three months before your 65th birthday, includes the month of your birthday, and ends three months later. Apply at any other time and you may face a lapse in coverage or penalties.
These penalties appear as premiums that increase by 10 percent for each 12-month period youre eligible for Part B but do not sign up. Also, if you bypass your Initial Enrollment Period, you can only sign up for Part B during the General Enrollment Period, with is January 1st to March 31st each year, with coverage beginning in July.
Now, lets say that youre okay with this and still want private insurance versus Medicare. If you go through the Marketplace to get that insurance, Healthcare.gov warns that it is illegal for anyone to sell you a Marketplace plan if they know that you have Medicare.
So, if you have already signed up for Medicare, the Marketplace is not an option for finding a new insurance plan. The only exception is if you are paying a premium for Medicare Part A. In this case, you can drop Medicare and go with a plan that you find on the Marketplace.
Additionally, if you are able to sign up for Medicarewhether due to age or disabilitybut have not, you can purchase a Marketplace plan then, too.
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How Are My Health Care Costs Reimbursed If I Have Medicare And Medicaid
When dual eligible beneficiaries have healthcare expenses, Medicare pays first and Medicaid pays last. But this is not the case for things Medicare doesnt cover, like long-term care. If Medicaid is covering a beneficiarys long-term care, Medicare will still be the primary payer for any Medicare-covered services like skilled nursing care or physical therapy.
Although it is less common, if a dual eligible individual has additional coverage then Medicare pays first, Medigap will pay second, and Medicaid is the last payer for their claims .
For More Information Specific To Your Medicare Policy
If you have Medicare and an additional insurance policy and youre still unsure which is primary and which is secondary, or if youd like to learn more about all of your insurance options even though you are or will be Medicare eligible, you can contact the Benefits Coordination & Recovery Center at 798-2627 .
You can also reach out to the State Health Insurance Assistance Program for assistance. To find your local SHIP, Medicare.gov offers an easy-to-use online SHIP search tool that will provide the information you need.
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Will Medicare Cover Me If I Live In Two States
By Dave Miller
Many seniors enjoy warm weather living year round by maintaining dual residence, or living for part of the year in two different states. Dual residence is nothing new, and snowbirds have been fleeing to southern states in winter for generations. But how does dual residence impact your Medicare options, will you still be covered if you live in two states? Heres some guidance on Medicare and what you should know if you head south for the winter.
C: Medicare Advantage Plans
With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were formally given the option to receive their Original Medicare benefits through capitated health insurance Part C health plans, instead of through the Original fee for service Medicare payment system. Many had previously had that option via a series of demonstration projects that dated back to the early 1970s. These Part C plans were initially known in 1997 as “Medicare+Choice”. As of the Medicare Modernization Act of 2003, most “Medicare+Choice” plans were re-branded as “Medicare Advantage” plans . Other plan types, such as 1876 Cost plans, are also available in limited areas of the country. Cost plans are not Medicare Advantage plans and are not capitated. Instead, beneficiaries keep their Original Medicare benefits while their sponsor administers their Part A and Part B benefits. The sponsor of a Part C plan could be an integrated health delivery system or spin-out, a union, a religious organization, an insurance company or other type of organization.
The intention of both the 1997 and 2003 law was that the differences between fee for service and capitated fee beneficiaries would reach parity over time and that has mostly been achieved, given that it can never literally be achieved without a major reform of Medicare because the Part C capitated fee in one year is based on the fee for service spending the previous year.
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If You Or Your Spouse Is Working While Abroad:
You can delay Medicare enrollment in Part B if you have health care coverage from:
- An employer for which you actively work and which provides group health insurance for you
- The public national health service of the country where you live regardless of whether you or your spouse works for an employer or are self-employed
- The sponsoring organization of voluntary service you provide abroad
When you stop working or lose your coverage from any of the above situations, you will be entitled to a special enrollment period of up to eight months to sign up for Medicare without risking late penalties. So if you stop working but dont return to the United States within that time frame, youll confront the same dilemma that nonworking people abroad face either sign up for Part B and pay premiums for coverage you cant use or delay enrollment until your return to the U.S. and then become liable for permanent late penalties.
The rules for Part D drug coverage are the same as those noted in the information provided above for nonworking Americans abroad.
Get Answers To Your Medicare Questions
If you want more information about where you can use your Medicare plan and how to ensure you have the coverage you need when moving or traveling to another state, speak with a licensed insurance agent who can help answer your questions.
Explore Medicare Advantage plan benefits in your area
Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!
About the author
Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelors degree in journalism. He currently lives in Raleigh, NC.
Where you’ve seen coverage of Christian’s research and reports:
MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts enrollment in any plan depends upon contract renewal.
Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE , 24 hours a day/7 days a week or consult www.medicare.gov.
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Quality Of Beneficiary Services
A 2001 study by the Government Accountability Office evaluated the quality of responses given by Medicare contractor customer service representatives to provider questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer service representatives was 15%. Since then, steps have been taken to improve the quality of customer service given by Medicare contractors, specifically the 1-800-MEDICARE contractor. As a result, 1-800-MEDICARE customer service representatives have seen an increase in training, quality assurance monitoring has significantly increased, and a customer satisfaction survey is offered to random callers.
Does Medicare Cover Me While I Travel
Many older adults look forward to fulfilling their travel bucket list during retirement, but Medicare may not be along for the ride.
If you have Medicare coverage, you wont receive reimbursement for international medical bills. Healthcare services received beyond U.S. borders are not covered.
In some cases, Medicare may cover inpatient hospital costs, ambulance services or dialysis for the following circumstances:
In any of these situations, the foreign hospital is not required to file a Medicare claim. If it doesnt, be prepared to submit an itemized bill to Medicare.2
Your Medicare coverage follows you if you travel to:
- Another state in the U.S
- District of Columbia
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Does Medicare Cover Respite Care
Medicare only covers respite care for people who qualify for Medicare hospice care. In this case, Medicare will pay for respite care, along with room and board, in a Medicare-certified inpatient hospice facility.1 The stay may be no longer than five days in a row, and you may be responsible for paying five percent of the cost for inpatient care. More than one stay is allowed, but Medicare states that these should be occasional.
To qualify for Medicare hospice care, a hospice doctor and the person’s primary doctor must certify that they have a terminal illness and are expected to live no more than six months. In addition, the person must have chosen palliative hospice care rather than treatment for the illness. Medicare does not pay for respite care under any other circumstances.
FYI: Learn more about what Medicare does and doesn’t cover, as well as how to enroll, in our complete Medicare guide.
How To Compare Goodrx And Health Care Plan Prices
To compare medication prices at home, you’ll first need to check your insurance or Medicare plan’s price. If you have a health insurance or Medicare plan, you should be able to reference the full plan formulary by logging on to your insurance plan’s patient portal on the company’s website. The formulary will also include information on any restrictions, such as prior authorization or quantity limits, as well as whether you are under a deductible.
Your next step is to search for the same drug under GoodRx, which gives you access to free coupons and comparisons to retail price. Depending on your copay or coinsurance charge, you may find that GoodRx can save you money on one or more of your medications.
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How To Use Goodrx In Place Of Insurance
If you are planning to use GoodRx instead of your health insurance plan, you simply need to bring the applicable coupon to the designated pharmacy. GoodRx coupons are available to print from your desktop computer, but you can also send them directly to your mobile device, or access them instantly from within the GoodRx App on your phone. Ask the pharmacist to use the coupon and process the purchase as a “cash” transaction . They will use the code on your coupon to find your new price.
After using GoodRx instead of your health insurance plan, you can ask your insurer to reimburse you or to apply your purchase toward your deductible. Gather all of your receipts, fill out your insurer’s prescription reimbursement form, and mail the form and receipts to their address. Keep a copy of everything for your records. While reimbursement is not guaranteed and will vary based on insurance plan, it can be worth trying as a way to keep your health care costs down.