How Medicare Works With Your Other Insurance
When you have more than one insurance provider, there are certain rules that determine who pays what it owes first and who pays based on the remaining balance. For seniors who don’t have other insurance, Medicare is obviously the primary payer. However, when you have other insurance, it’s a little more complicated.
Depending on the type of insurance you have , Medicare can either be the primary or the secondary payer. If Medicare would be a secondary payer to your current insurance, you can delay signing up for Medicare Part B. If your current insurance would become a secondary payer to Medicare, you should sign up during your initial enrollment period, which is the seven-month period that begins three months prior to the month you’ll turn 65.
It’s also worth noting that although I’m specifically mentioning Medicare Part B, which is medical insurance, this applies to Part A as well. However, Medicare Part A is free to the vast majority of Americans, so it’s probably worth signing up for Part A whether you’re required to or not. On the other hand, Medicare Part B has a monthly premium you’ll have to pay , which is why it can make sense to delay signing up if it’s not going to be your primary insurance.
What Factors Affect How You Can Build Your Health Coverage
When you have multiple options, there are several factors that will determine the best structure for your health insurance coverage. Those factors include:
Whether your spouse has health insurance
Whether you like the doctors or hospitals in your private plans network
The out-of-pocket costs of both primary and secondary insurance
The total out-of-pocket costs for each policy would include, among others:
Out-of-pocket prescription costs, which are dictated by your plans drug formulary
If you get health insurance through an employer that has fewer than 20 workers, youll have to purchase Medicare when you turn 65, and that will be your primary coverage.
Another factor to consider: whether you have creditable drug coverage. Medicare requires everyone 65 and older to have adequate prescription drug coverage, so you may need to purchase a standalone Part D plan if your employer plan does not qualify. Your plan provider can tell you whether or not your prescription drug coverage is creditable.
Its important to tell your doctor or healthcare provider if you have multiple insurers. In cases where you get treatment and your private insurance does not pay for a service that Medicare believes should be covered, Medicare may make a conditional payment on your behalf.
Employer Or Military Retiree Coverage
If you or your spouse has an Employer Group Health Plan as retiree health coverage from an employer or the military , you may not need additional insurance. Review the EGHPs costs and benefits and contact your employer benefits representative or SHIIP to learn how your coverage works with Medicare.
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.
Secondary And Primary Insurers
The payment structure is one factor that can help you decide whether it is worth it to continue to receive employee group coverage. After age 65, your group insurance can either become your primary or secondary insurer. Whichever it becomes can be based on your companys size or other factors.
If your group plan remains your primary insurer, your existing coverage will continue to pay for its benefits, as it would normally. If your employer has coverage that is primary, you generally do not need to sign up for Medicare Part B . You may still want the extra coverage from Medicare, so it is best to look into exactly what benefits you could be getting from both insurances before you make a decision.
If your group plan becomes your secondary insurer, it pays second. The secondary plan covers all or some of the health care expenses that the primary insurer has not paid. For example, a secondary insurer could pay the 20 percent coinsurance on a service covered by Original Medicare. If you have secondary insurance and do not have primary insurance, you risk having very little coverage for necessary medical services.
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Where To Get More Details
If you have additional questions about who pays your Medicare bills first, contact your insurance provider or call Medicares Benefits Coordination & Recovery Center at 855-798-2627 .
Medicare And Workers Compensation
Workers compensation always pays first when youre using it alongside Medicare. Thats because workers compensation is an agreement that your employer will pay medical costs if youre hurt at work. In return, you agree not to sue them for damages. Since your employer has agreed to pay, Medicare will not pay until the benefit amount of your workers compensation is completely spent.
However, sometimes a workers compensation case needs to be investigated or proven before its approved. In this case, Medicare will act as a temporary primary payer. When your claim is approved, workers compensation will reimburse Medicare. Youll also be reimbursed for any coinsurance or copayments you made.
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How Does Medicare Work As A Secondary Payer
Knowing what it means for Medicare to be the secondary payer for health coverage can help you understand how your health care is paid for and what you can expect from the way Medicare coordinates with other insurance providers.
Understanding What Primary and Secondary Payer Means
In the simplest of terms, a primary payer will cover the cost of a health care bill according to its policy rules and up to the limit established therein.
A secondary payer assumes coverage of whatever amount remains after the primary payer has satisfied its portion of the benefit, up to any limit established by the policies of the secondary payer coverage terms.
When Medicare coordinates benefits with other health insurance coverage providers, there are a variety of factors that play into whether Medicare is the primary, secondary or, in very rare cases, a tertiary payer.
Common Circumstances Where Medicare is the Secondary Payer
Generally, a Medicare recipients health care providers and health insurance carriers work together to coordinate benefits and coverage rules with Medicare. However, its important to understand when Medicare acts as the secondary payer if there are choices made on your part that can change how this coordination happens. This will reduce the risk of you winding up with any unexpected out-of-pocket charges.
Medicare is the secondary payer if the recipient is:
Why Is Medicare Advantage A Bad Choice
Medicare Advantage can become expensive if you’re sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patient’s choice. It’s not easy to change to another plan if you decide to switch to Medigap, there often are lifetime penalties.
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Do I Have Other Coverage Options Besides Original Medicare
Original Medicare is the government-run program, but it may not be your only coverage option as a Medicare beneficiary. As mentioned, Medicare Prescription Drug Plans provide stand-alone prescription drug benefits, and Medicare Supplement plans are also available to help with out-of-pocket costs in Original Medicare. You can also opt to enroll in a Medicare Advantage plan as an alternative way to get your Medicare Part A and Part B coverage. These plans cover at least the same level of benefits as Original Medicare, Part A and Part B. But the benefit of these plans is that you may have the option to get additional coverage not covered by Original Medicare, such as routine vision or dental, hearing, wellness programs, and prescription drugs.
Need help finding Medicare plan options that may work for your situation? You can get personalized assistance with your questions with a licensed insurance agent just pick up the phone and call eHealth to get help.
This website and its contents are for informational purposes only. Nothing on the website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.
Medicare And Veterans Benefits
You can also use your veterans benefits alongside Medicare. As a veteran, you have healthcare coverage through a program called TRICARE.
Once you reach age 65, youll need to enroll in Medicare to keep using your TRICARE plan. Medicare and TRICARE work together in a unique way to cover a broad range of services. The primary and secondary payer for services can change depending on the services you receive and where you receive them.
- TRICARE will pay for services you receive from a Veterans Administration hospital.
- Medicare will pay for services you receive from a non-VA hospital.
- Medicare will be the primary payer for Medicare-covered services and TRICARE will pay the coinsurance amount.
- TRICARE is the primary payer for services not covered by Medicare.
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How Do You Know If Medicare Is Primary Or Secondary
Medicare and your other insurance plans coordinate their benefits to avoid duplicate payments. If Medicare is your primary payer, it will pay first and your private plan will kick in to cover some or all of the costs not covered by Medicare. If Medicare is secondary, the opposite will occur.
Typically, whether Medicare is primary or secondary to your existing insurance will depend on how you get your other insurance policy. If you work for a large employer , your workplace insurance is your primary policy. The same rule applies if you get insurance through your spouses large employer. Similarly, if youre on active-duty military and get insurance through Tricare, Medicare will be secondary.
However, if you work for a small company or get health insurance from a former employer, Medicare pays first.
In any case, even if both insurers pay a portion of the costs, you may still end up owing money for your treatment if the two insurers dont completely cover your copayment or deductible.
How Does Tricare For Life Work With Medicare Advantage
Some TRICARE For Life beneficiaries choose to enroll in Medicare Advantage plans to access benefits such as gym memberships and dental, vision, and hearing coverage. As Medicare doesnt cover these benefits, an Advantage plan is a means for the beneficiary to obtain them. Before you enroll in a Medicare Advantage plan, make sure your health care providers are in the plan network meaning they accept your coverage.
For example, if you have a Medicare Advantage HMO plan and TFL, the HMO is your primary insurance, and TFL acts as a supplement. If you receive care outside your HMO network, the HMO wont cover any of the costs. Any claim will be forwarded to TFL.
Anything the Advantage plan doesnt cover, TFL will help to cover. This includes copays and deductibles, for which you would be otherwise responsible.
Therefore, if your providers are in your network, you may ultimately have no out-of-pocket expenses once TFL has paid its share. Thus, underscoring the importance of ensuring your providers are in-network before signing up for a Medicare Advantage plan.
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If You Have Or Can Get Both Medicare And Veterans’ Benefits You Can Get Treatment Under Either Program
If you have or can get both Medicare and Veterans benefits, you can get treatment under either program. Generally, Medicare and VA cant pay for the same service or items. Medicare pays for Medicare-covered services or items. Veterans Affairs pays for VA-authorized services or items.
When you get health care, you must choose which benefits to use each time you see a doctor or get health care.
To get the U.S. Department of Veterans Affairs to pay for services, you must go to a VA facility or have the VA authorize services in a non-VA facility.
If the VA authorizes services in a non-VA hospital, but didnt authorize all of the services you get during your hospital stay, then Medicare may pay for the Medicare-covered services the VA didnt authorize.
For active-duty military enrolled in Medicare, TRICARE pays for Medicare-covered services or items, and Medicare pays second
For inactive-duty military, Medicare pays first for Medicare-covered services and TRICARE may pay second.
TRICARE pays first for services or items from a military hospital or any other federal provider
Get more information on TRICARE.
Medicare Prescription Drug Coverage
Medicare Prescription Drug Plans are sold by private insurance companies approved by Medicare. All people new to Medicare have a seven-month window to enroll in a PDP three months before, the month of and three months after their Medicare becomes effective. The month you enroll affects the PDPs effective date. All people with Medicare are eligible to enroll in a PDP however, unless you are new to Medicare or are entitled to a Special Enrollment Period, you must enroll or change plans during the Open Enrollment Period for Medicare Advantage and Medicare Part D, Oct. 15 through Dec. 7. There is a monthly premium for these plans. If you have limited income and assets/resources, assistance is available to help pay premiums, deductibles and co-payments. You may be entitled to Extra Help through the Social Security Administration. To apply for this benefit contact SHIIP at 1-855-408-1212 or the Social Security Administration at 800-772-1213 or www.socialsecurity.gov.
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How Tricare Works With Medicare
Beneficiaries eligible for both TRICARE and Medicare should understand how the two medical insurance programs work together. Medicare consists of a few different parts. If youre familiar with these parts, you might be wondering how each works with TRICARE, and if additional supplemental insurance is necessary for those who are dual-enrolled in both Original Medicare and TRICARE.
TRICARE For Life is the health insurance program available to U.S. military retirees who qualify, as well as their beneficiaries, for no cost. Its different and separate from Medicare. Medicare is the U.S. national health insurance program for individuals 65 years of age and older or who are disabled. Its crucial for those who are dual-eligible to understand their coverage options.
How Medicare Part D Works With Other Insurance Coverage
Perhaps you currently have insurance coverage that includes prescription drug coverage and wonder if you still need coverage under Medicare Part D. That will depend upon the source of your insurance coverage. Here are some things you may want to consider:
- Will your current insurance plan coordinate benefits with Medicare?
- If you enroll in a Medicare Prescription Drug Plan, will you lose your other insurance coverage? And if so, will it affect your spouse, partner or others who may be covered by the plan?
- Does your current insurance provide as good, if not better, prescription drug coverage as Medicare Part D provides? That is, does it provide creditable coverage?
Here are some examples of other insurance coverage that Medicare-eligible people might have:
How Medicare Part D might work with an employer or union plan
An employer or union plan decides how it works with Medicare and whether or not it will coordinate benefits with Medicare. Your employer or union should tell you if your present prescription drug coverage will change when you become eligible for Medicare. This notification also applies to your spouse if he or she is covered under your employer health plan and becomes eligible for Medicare.
Your employer might do any of the following:
- Continue your current coverage
- Offer alternative coverage through a specified Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug Plan
- Drop your coverage
How Medicare Part D might work with COBRA
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