Medicare: To Carry Or Not?

Medicare is a federal insurance program for people over 65 and certain younger people with disabilities or specific health conditions. It is not mandatory to carry Medicare insurance, but it is highly recommended for those who meet the eligibility criteria. If you are covered by Medicare Part C (Medicare Advantage), you do not need to carry your Medicare card as your private health insurance company takes its place. However, if you are on Medicare Parts A and B, it is advisable to always have the card with you when visiting a doctor or hospital.

Medicare and private insurance can coexist, but which provider pays first depends on your situation

Medicare and private insurance can coexist, but it can be a complicated process to understand which provider pays first and for what. This depends on your situation and the type of private insurance you have.

When you have more than one type of insurance coverage, each type is called a "payer". When there is more than one payer, "coordination of benefits" rules decide which insurance provider pays first. The "primary payer" pays what it owes on your bills first, and then sends the rest to the "secondary payer" to pay. In some rare cases, there may also be a third payer.

The insurance that pays first (primary payer) pays up to the limits of its coverage. The secondary payer only pays if there are costs the primary insurer didn't cover, but it may not pay all the remaining costs.

If you have private insurance through your employer or your spouse's employer, the number of employees in the company will play a role in determining which insurance is the primary payer. If your company has 20 or more employees, the private health coverage will be the primary payer. However, if your company has fewer than 20 employees, Medicare is the primary payer.

If you have a disability and qualify for Medicare, your company must have 100 or more employees to be your primary payer. If the company has fewer than 100 employees, Medicare is the primary payer.

If you have End-Stage Renal Disease (ESRD), your private insurance plan will pay for the first 30-month period of medical expenses. Medicare will then become the secondary payer.

If you qualify for retiree coverage, Medicare is the primary payer, while private insurance is secondary.

Regarding Medicare and COBRA, Medicare pays first for individuals over 65 or with disabilities. If you have ESRD, COBRA will pay first. Medicare may pay second, depending on the specific plan details.

TRICARE is a healthcare program designed for service members and their families. If you are on active duty, TRICARE is the primary payer and will cover Medicare deductibles and coinsurance costs. If you are not on active duty, Medicare is the primary payer. However, TRICARE is the secondary payer if you have TRICARE for Life coverage.

If you have questions about how Medicare works with private insurance, you can contact several sources for assistance, including Medicare, the Social Security Administration (SSA), or your local State Health Insurance Assistance Program (SHIP).

Medicare Part A covers inpatient hospital stays, hospice care, and some home health care

Medicare is a federal insurance program for people over 65 and certain people with disabilities or specific health conditions. It is administered by the federal government, and benefits, premiums, and cost-sharing structures are decided at the federal level.

Medicare Part A, also known as Hospital Insurance, covers inpatient hospital stays, hospice care, and some home health care. Inpatient care in a hospital is covered by Medicare Part A. This includes skilled nursing facility care and inpatient respite care.

Medicare Part A also covers hospice care for those who are terminally ill and have a life expectancy of 6 months or less. To qualify for hospice care, you must meet certain conditions, including accepting comfort care instead of treatment to cure your illness, and choosing hospice care over other Medicare-covered treatments for your terminal illness. You can usually receive hospice care in your home or another facility, such as a nursing home. While you won't have to pay for hospice care, you may have to pay a small copayment for inpatient respite care and outpatient drugs for pain and symptom management.

Additionally, Medicare Part A covers some home health care services. This includes nursing and medical services, durable medical equipment, medical supplies, and physical therapy services. These services aim to provide comfort and support to individuals receiving hospice care and their families.

It is important to note that Medicare Advantage Plans or other Medicare plans may have different rules regarding coverage. However, these plans must provide at least the same level of coverage as Original Medicare.

Medicare Part B covers certain doctor services, outpatient care, and medical supplies

Medicare is a federal insurance program for people over 65 and certain people with disabilities or a health condition such as end-stage renal disease (ESRD) and Lou Gehrig's disease (ALS). There are two main ways to get your Medicare coverage: Original Medicare and Medicare Advantage.

Original Medicare includes Part A and Part B. Part A (Hospital Insurance) covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care. Part B (Medical Insurance) covers services from doctors and other healthcare providers, durable medical equipment, and many preventive services.

Part B covers durable medical equipment (DME), such as wheelchairs, walkers, and hospital beds. It also includes partial hospitalization and intensive outpatient program services. Additionally, it covers limited outpatient prescription drugs.

If you use an insulin pump covered under Part B's durable medical equipment benefit, your cost for a month's supply of insulin can't exceed $35. If you get a 3-month supply, your costs can't be more than $35 per month. This means you generally won't pay more than $105 for a 3-month supply of covered insulin.

Medicare Part B is an essential component of Original Medicare, providing coverage for doctor services, outpatient care, and medical supplies needed for diagnosis, treatment, and prevention.

Medicare Part C, or Medicare Advantage, is an alternative way to receive your benefits through private insurance companies

Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These "bundled" plans include Part A, Part B, and usually Part D (drug coverage). In most cases, you will need to use doctors who are in the plan's network.

Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). Medicare pays a fixed amount for your care every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist). These rules can change each year.

Medicare Advantage Plans are sometimes called "Part C" or "MA Plans" and are offered by private companies approved by Medicare. You are still enrolled in Medicare, but the Medicare Advantage plan administers your benefits. The plan sets its premiums, deductibles, and coinsurance/copayment amounts. Most Medicare Advantage plans include prescription drug coverage, and many have extra benefits, like routine dental care.

Medicare Part D helps cover the cost of prescription drugs

Medicare Part D is a voluntary outpatient prescription drug benefit for people with Medicare. It is provided through private plans that contract with the federal government. Beneficiaries can choose to enroll in either a stand-alone prescription drug plan (PDP) to supplement traditional Medicare or a Medicare Advantage plan, mainly HMOs and PPOs, that provides all Medicare-covered benefits, including prescription drugs (MA-PD).

Medicare Part D prescription drug plans are offered by private health insurance companies and cover your prescription drug costs for covered medications. Part D coverage is generally included in most Medicare Advantage (Part C) plans. Most Part D plans require a monthly premium, and some have deductibles. Many also require that you pay a fixed copayment each time you fill a prescription, while some require that you pay a percentage (coinsurance) of a medication's cost.

Most plans have a monthly premium that you pay in addition to your Part B premium. You'll also pay other costs when you get prescriptions. Plans divide the covered drugs on their formulary into groups called "tiers" based on cost. A drug in a lower tier will cost less than a drug in a higher tier.

Part D insurance premiums may change each year. You will be notified of these changes in the fall before the annual Open Enrollment Period.

Frequently asked questions