Orlando Harmon
Medicare is the US federal government's health insurance program for people over 65, and younger people with disabilities. It is possible to have Medicare and another form of health insurance at the same time. This is called retiree coverage, and in this case, Medicare usually pays first, and the other insurance pays second. There are several situations in which an individual may have private insurance and Medicare at the same time. For example, COBRA allows individuals to keep their private insurance coverage after their employment ends. TRICARE provides coverage for active and retired military personnel and their dependents, and can be used in conjunction with Medicare.
| Characteristics | Values |
|---|---|
| Can you have Medicare and other health insurance? | Yes |
| What are they called? | Each type of coverage is called a "payer" |
| Who pays first? | It depends on which insurance is considered "primary" and which is "secondary". The primary payer pays up to the limits of its coverage, and the secondary payer covers any remaining costs. |
| What if the primary payer doesn't pay the claim promptly? | Medicare may make a conditional payment to pay the bill and then recover any payments from the primary payer. |
| What if I have questions about who pays first or my coverage changes? | Call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627) |
| What if I want drug coverage? | You can join a separate Medicare drug plan, as drug coverage is optional. |
| Can I get prescription drug coverage from Medicare? | Yes, from a private health insurance company that contracts with Medicare. |
| Can I buy private insurance instead of Medicare? | Yes, there are exceptions, such as if you are eligible for Medicare due to end-stage renal disease (ESRD) but haven't signed up. |
| Can I sign up for Medicare if I have private insurance? | Yes, you can generally sign up for a Medicare Advantage plan or a stand-alone Medicare Part D prescription drug plan. |
| Can I get Medicare and private insurance at the same time? | Yes, in certain situations, such as having retiree coverage or being covered under a spouse's plan. |
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What You'll Learn
Medicare and private insurance
Medicare is a public health insurance program that is government-funded. Private health insurance plans, on the other hand, are offered by private companies. It is possible to have both Medicare and private insurance at the same time. This can happen if you have coverage through your employer, your spouse's employer, COBRA, or TRICARE. If you have both, a process called "coordination of benefits" determines which insurance provider pays first. This provider is called the "primary payer". The primary payer pays for any covered services until the coverage limit has been reached. The other provider is called the "secondary payer" and they pay for costs that the primary payer doesn't cover. However, the secondary payer may not cover all the remaining costs, in which case you may be responsible for the rest of the bill.
There are certain situations in which you may lose your employer or union health and drug coverage for you and your dependents. For instance, if you have employer coverage and get Medicare drug coverage, you may lose your employer coverage. Additionally, Medicare can't pay for items or services that workers' compensation will pay for promptly.
If you have questions about who pays first or if your coverage changes, you can call the Benefits Coordination & Recovery Center at 1-855-798-2627. It is important to tell your doctor and other healthcare providers about any changes in your insurance or coverage.
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Primary and secondary insurance
It is possible to have Medicare and another insurance plan simultaneously. In such cases, one insurance is considered the "primary payer", paying the initial portion of the claim up to its coverage limits, while the other is deemed the "secondary payer", covering some or all of the remaining costs. This process is called "coordination of benefits" (COB). The coordination of benefits framework ensures that both health plans pay their fair share without paying more than 100% of the medical costs.
The primary payer is typically the main source of coverage, while the secondary payer acts as a supplemental policy to fill in any gaps or additional expenses not covered by the primary payer. The primary payer is usually billed first and is responsible for paying a majority of the costs. The secondary payer may cover expenses that are not covered by the primary payer or pay the remaining costs after the primary payer has paid its portion. It is important to note that the individual may still be responsible for some out-of-pocket costs, such as deductibles, copay, and coinsurance fees.
The determination of which insurance is primary and which is secondary depends on the type of private insurance and the individual's situation. For example, if an individual has Medicare and employer-provided insurance, Medicare is usually the primary payer if the individual is 65 or older and their employer has fewer than 20 employees. On the other hand, if an individual is covered by their spouse's insurance and their own insurance, their spouse's insurance is typically the primary payer.
Having dual health insurance plans can help reduce out-of-pocket medical expenses. However, it is important to be aware that having two health plans may also result in paying two premiums and facing two deductibles, potentially increasing overall health expenses. It is recommended to inform healthcare providers about all insurance plans to ensure proper coordination of benefits and accurate billing.
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Medicare and Medicaid
Medicare is a federal health insurance program for individuals who are 65 or older, younger people with disabilities, and people with End Stage Renal Disease. It is available in two forms: Original Medicare and Medicare Advantage. Original Medicare is a pay-as-you-go service in which Medicare pays a portion of the cost, and the user pays the remainder. Medicare Advantage, on the other hand, is provided by a private insurance company that has been approved by Medicare and follows its rules. Medicare Part B covers medical services like doctors' services, outpatient care, and other services that Part A does not cover. Medicare Part D provides prescription drug coverage.
Medicaid, on the other hand, is a joint federal and state program that provides health coverage to people with low incomes and limited resources. Eligibility and benefits vary from state to state. While the federal government sets general rules, each state runs its own program with its own eligibility requirements. Medicaid covers services that Medicare does not, such as nursing home care and personal care services. People with Medicaid usually do not pay anything for covered medical expenses but may owe a small co-payment for some items or services.
It is possible to have both Medicare and private insurance at the same time. When this happens, a process called "coordination of benefits" determines which insurance provider pays first. This provider is called the "primary payer". The primary payer pays for any covered services until the coverage limit is reached, after which the "secondary payer" pays for any remaining costs. If the secondary payer does not cover the remaining balance, the patient may be responsible for the remaining costs.
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Medicare and COBRA
COBRA, or the Consolidated Omnibus Budget Reconciliation Act, is a law that helps provide health insurance to employees in certain situations where they may otherwise lose their coverage for 18 to 36 months. This usually applies when someone experiences a reduction in work hours or loses their job. It can also apply if they lose their coverage as a spouse or dependent of the covered employee. In general, COBRA applies to employers with 20 or more employees, but some states have mini-COBRA laws that cover smaller businesses.
Medicare, on the other hand, is a public health insurance program that people become eligible for at age 65. However, people can also become eligible for Medicare before the age of 65 under certain conditions, such as having a disability or End-Stage Renal Disease (ESRD). When someone becomes eligible for Medicare, it usually becomes their primary insurance, meaning it pays for health care costs first. Any other insurance, like COBRA, becomes the secondary payer and covers any costs that Medicare does not.
If someone has COBRA coverage and then becomes eligible for Medicare, it is important that they enroll in Medicare Part B as soon as they are eligible. If they do not, they may have to pay a Part B late enrollment penalty. Additionally, if they want Medicare Part D prescription drug coverage, they may be able to delay enrolling without penalty if their COBRA coverage includes creditable prescription drug coverage. However, once their COBRA coverage ends, they will only have 63 days to enroll in Medicare Part D without penalty.
It is possible to have both Medicare and COBRA coverage at the same time, but it depends on which form of insurance someone gets first. If someone has COBRA coverage and then becomes eligible for Medicare, their COBRA coverage will usually end, and Medicare will become their primary insurance. If someone is already enrolled in Medicare Part A or B and then becomes eligible for COBRA, they can enroll in COBRA as a secondary payer. However, it is important to note that COBRA is typically expensive, so it may not be worth keeping unless it covers Medicare cost-sharing or offers other needed benefits.
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Medicare and TRICARE
Medicare is a federal health insurance program for people aged 65 or older, people under 65 with certain disabilities, people of any age with end-stage renal disease, ALS (Lou Gehrig's disease), or mesothelioma.
TRICARE, on the other hand, provides coverage for active and retired military personnel and their dependents. It is important to note that TRICARE is not just for those who are 65 or older. If you have Medicare due to a disability, you can continue your TRICARE Prime enrollment if you qualify, and your Prime enrollment fees will be waived.
If you are eligible for both TRICARE and Medicare, you can have both. However, to keep your TRICARE coverage, you must also have Medicare Part B if you are eligible for Medicare Part A. If you are receiving Social Security Disability payments, you will automatically get Medicare Part A and Part B in the 25th month of disability.
If you do not sign up for Medicare Part B when you first become eligible, you can sign up during the general enrollment period (January 1 - March 31 each year). Your coverage will then start the first day of the month after you sign up. However, you may have to pay a late enrollment penalty, and your monthly premium for Part B may increase.
Medicare may be the primary or secondary payer, depending on the type of private insurance you have and your individual situation. If you have questions about who pays first or if your coverage changes, you can call the Benefits Coordination and Recovery Center.
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Frequently asked questions
Yes, you can have Medicare and other insurance. Each type of coverage is called a "payer". The primary payer pays up to the limits of its coverage, and the secondary payer covers any costs the primary insurance didn't.
The primary payer depends on the type of private insurance you have and your individual situation. In some cases, Medicare may be the primary payer, and in others, it may be the secondary payer.
If your insurance company doesn't pay your claim within 120 days, your doctor or healthcare provider may bill Medicare. Medicare may make a conditional payment to pay the bill and then recover any payments from the primary payer.
Original Medicare, Part A and Part B, do not include prescription drug coverage. You can get prescription drug coverage from a private health insurance company that contracts with Medicare.
Yes, there are exceptions where you can buy private insurance instead of Medicare. For example, if you are eligible for Medicare due to end-stage renal disease (ESRD) but haven't signed up, or if you aren't collecting Social Security benefits.
