Jane Dotson
Medicare is a federal health insurance program for people aged 65 and older, as well as some younger people with disabilities or end-stage renal disease. It consists of four parts: Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage), and Part D (Prescription Drug Coverage). Medicare Advantage plans are offered by private insurance companies like Humana, which contract with the federal government. When an individual has Medicare and other health insurance, each type of coverage is called a payer. The primary payer pays up to the limits of its coverage and then sends the remaining balance to the secondary payer. Medicare is widely accepted across the US, with most healthcare providers accepting it.
| Characteristics | Values |
|---|---|
| Medicare | A federal health insurance program for people aged 65 and older, as well as some younger people with disabilities, or any age with end-stage renal disease (ESRD) |
| Types of Medicare | Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage), Part D (Prescription Drug Coverage) |
| Humana | A private insurance company contracted by the federal government to offer Medicare Advantage plans |
| Primary and Secondary Insurance | The primary payer pays up to the limits of its coverage, then sends the remaining balance to the secondary payer. If the secondary payer doesn't cover the remaining balance, the individual may be responsible for the remaining costs |
| Medicare and Other Insurance | Medicare can be the primary or secondary payer depending on the situation. For example, if an individual has Medicare and employer insurance, Medicare may be the primary payer |
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What You'll Learn
Medicare Part A and Part B
Medicare is a federal health insurance program for people aged 65 and older and some individuals under 65 with certain disabilities or conditions. Medicare Part A and Part B, also known as Original Medicare, are the two fundamental components of Medicare.
Medicare Part A, or Hospital Insurance, covers inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. Most people are eligible for premium-free Part A if they meet certain requirements, such as receiving Social Security or Railroad Retirement Board (RRB) benefits, having worked a certain number of quarters, or having end-stage renal disease. Individuals who do not qualify for premium-free Part A can purchase it by paying a premium.
Medicare Part B, or Medical Insurance, covers certain doctors' services, outpatient care, medical supplies, and preventive services. To enrol in Medicare Part B, individuals must meet certain eligibility criteria, such as being 65 years or older, or having a qualifying disability. Some individuals may need to pay a monthly premium for Part B coverage.
If you have both Medicare and other health insurance, such as from an employer or a group health plan, each type of coverage is called a "payer." The "primary payer" pays up to its coverage limits and then sends the remaining balance to the "secondary payer." Medicare Advantage (Part C) is an alternative to Original Medicare, offering bundled coverage of Part A, Part B, and often Part D (prescription drug coverage).
It's important to understand the coordination of benefits when having multiple insurance plans. In most cases, Medicare serves as the primary payer, and the secondary payer covers any remaining costs after Medicare has paid its share. However, if Medicare is the secondary payer, you may need to enrol in Medicare Part B for your other insurance to pay for Part B services.
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Medicare Advantage Plans
It is important to note that Medicare Advantage Plans are not available in all areas, and the availability of specific plans may vary from state to state or even within different counties within a state. Insurance companies have the flexibility to decide on the availability of their plans, and they can choose to offer multiple plans in an area with varying benefits and costs. This allows individuals to choose a plan that best suits their needs and budget.
Before enrolling in a Medicare Advantage Plan, it is advisable to consult your employer, union, or benefits administrator to understand the potential impact on your existing coverage. In some cases, joining a Medicare Advantage Plan may result in the loss of employer or union coverage, which could also affect the coverage of your spouse and dependents. Therefore, it is essential to carefully review the rules and consider all your options before making any changes to your healthcare plan.
Additionally, it is worth mentioning that Medicare Advantage Plans have specific disenrollment criteria. For instance, if you move outside the plan's service area, lose Medicare or Medicaid eligibility, join a different drug plan, or if the plan's contract with Medicare ends, you may be disenrolled from the Medicare Advantage Plan. In such situations, a grace period is provided during which you are eligible for a Special Enrollment Period, allowing you to explore other Medicare health plan options to ensure continued coverage.
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Medicare with other insurance
Medicare is a public health insurance program, while private insurance is provided by private companies. In certain instances, private health insurance and Medicare can be combined. For example, you can have Medicare and also be covered by a group plan provided by your spouse's employer.
If you have Medicare and another health insurance plan, each type of coverage is called a "payer". The "primary payer" pays up to the limits of its coverage and then sends the remaining balance to the "secondary payer". If the "secondary payer" doesn't cover the remaining balance, you may be responsible for the remaining costs.
Medicare may be the primary payer, the secondary payer, or may not have any cost-sharing responsibility when you receive care. If Medicare is your primary payer, it will pay first, and your other plan may cover the remaining expenses. If Medicare is the secondary payer, the other plan pays first, and Medicare may cover all, part, or none of the remaining cost.
There are several situations in which you may have private insurance and Medicare at the same time. For example, you may have employer-provided insurance while also being eligible for Medicare. In this case, your employer-provided insurance will typically be the primary payer, and Medicare will be the secondary payer. If you have insurance through your employer and Medicare but receive services outside of your insurance network, it's possible that neither Medicare nor your insurance plan will pay for the care.
If you have Medicare and Medicaid, you are considered "dual eligible". In most cases, Medicare will be your primary plan and cover most Medicare-eligible healthcare services, while Medicaid will be the secondary plan and cover medical costs that Medicare doesn't.
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Medicare eligibility
Medicare is a health insurance program for people aged 65 or older. However, you may be able to get Medicare earlier if you have a disability, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or ALS (also known as Lou Gehrig's disease).
If you are already receiving Social Security benefits before turning 65, you will be automatically enrolled in Medicare. If not, you will need to sign up for it actively.
Medicare Part A (Hospital Insurance) helps cover services received in a hospital or long-term care setting. Most people don't pay a premium for Part A coverage, also known as "premium-free Part A." You won't have to pay a Part A premium if you:
- Are already receiving retirement or disability benefits from Social Security or the Railroad Retirement Board.
- Get Medicare earlier than 65 due to a disability.
- Are 65 or older, and you or another qualifying person (like your current or former spouse) paid Medicare taxes while working for at least 10 years.
Medicare Part B (Medical Insurance) covers certain doctors' services, outpatient care, medical supplies, and preventive services. You will have to pay a premium for Part B coverage every month, even if you don't use any of the covered services.
Medicare Part C, also known as Medicare Advantage, is a set of private insurance plans that provide all of Part A and Part B coverage and typically offer extra benefits such as vision, hearing, and dental care.
Medicare Part D (Prescription Drug Coverage) is another set of private insurance plans that help cover the cost of prescription drugs.
If you have Medicare and other health insurance (like from an employer or Medicaid), each type of coverage is called a "payer." The "primary payer" pays up to the limits of its coverage and then sends the rest of the balance to the "secondary payer." If the secondary payer doesn't cover the remaining balance, you may be responsible for the remaining costs.
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Medicare and Medicaid
Medicare Part A (Hospital Insurance) helps cover services received in a hospital or long-term care setting. Part B (Medical Insurance) covers certain doctors' services, outpatient care, medical supplies, and preventive services. Medicare Part C, also called Medicare Advantage, is a private insurance plan that provides all of Part A and Part B coverage and typically offers extra benefits such as vision, hearing, and dental care.
Medicaid is a joint federal and state program that helps cover medical costs for certain low-income people, families, children, pregnant women, the elderly, and people with disabilities. Each state has its own Medicaid program with varying eligibility requirements and benefits. Medicaid offers benefits not typically covered by Medicare, such as nursing home care and personal care services.
If an individual qualifies for both Medicare and Medicaid, they are considered "dual eligible." In this case, Medicare is usually the primary payer, and Medicaid pays for any remaining costs for items and services it covers. The state may also pay for Medicare Part B premiums, deductibles, coinsurance, and copayments for those with full Medicaid coverage.
It is important to note that Medicare does not automatically know if an individual has other coverage. However, insurers must report to Medicare when they are the primary payer on medical claims.
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Frequently asked questions
Medicare is a federal health insurance program for people aged 65 and older, as well as some younger people with disabilities, or any age with end-stage renal disease.
Humana is a private insurance company that offers Medicare Advantage plans, also known as Medicare Part C. These plans provide the same healthcare services as Original Medicare (Part A and Part B), and often include extra benefits such as vision, hearing, and dental care.
The primary payer is the insurance that pays first. It pays up to the limits of its coverage, and then sends the rest of the balance to the secondary payer. If you have Medicare and Humana, Medicare is typically the primary payer, but it depends on your specific plan and coverage.
Original Medicare (Part A and Part B) is managed by the federal government and provides nationwide coverage. Medicare Advantage plans are offered by private insurance companies and may have provider networks that are limited to a specific area. Medicare Advantage plans often include additional benefits beyond Original Medicare.
Most individuals will automatically be enrolled in Medicare when they turn 65. If you are also interested in a Medicare Advantage plan through Humana, you can explore their plans in your area and sign up during the Initial Enrollment Period, which begins 3 months before you turn 65 and ends 3 months after.
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