Orlando Harmon
Medicare is a health insurance program provided by the US federal government, primarily for people aged 65 and above. It is also offered to younger people with disabilities or those with End-Stage Renal Disease. Medicare benefits are also sometimes offered to retirees of specific programs, such as Railroad workers and United Mine Workers (UMWA). UMWA is a health and retirement fund program that offers benefits to mine workers and their families. It is a managed-care plan and may require authorization. Medicare and UMWA can be used together, with one being the primary payer and the other the secondary payer. The primary payer pays up to the limits of its coverage, after which the secondary payer covers the remaining balance, if any.
| Characteristics | Values |
|---|---|
| UMWA Funds coverage | Skilled care in a skilled nursing facility after Medicare's 100 days, certain disposable supplies, routine immunizations |
| Medicare coverage | Chiropractic services for manual manipulation of a subluxated spine |
| Medicare eligibility | People age 65 or older, younger people with disabilities, people with End Stage Renal Disease |
| Types of Medicare coverage | Part A (Hospital Insurance), Part B (Medical Insurance) |
| UMWA Medicare Advantage Plans | Available between October 15th and December 7th |
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What You'll Learn
Medicare Part A and Part B
Medicare is federal health insurance for anyone aged 65 and older, as well as some people under 65 with certain disabilities or conditions. There are two types of Medicare coverage that individuals are required to enroll in when they become eligible: Part A (Hospital Insurance) and Part B (Medical Insurance).
Medicare Part A helps cover inpatient care in hospitals, skilled nursing facility care, hospice care, and home health care. Most people get Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage (QCs) and file an application for Social Security or Railroad Retirement Board (RRB) benefits. The exact number of QCs required is dependent on whether the person is filing for Part A on the basis of age, disability, or End Stage Renal Disease (ESRD). Individuals are eligible for premium-free Part A if they receive regular dialysis treatments or a kidney transplant, have filed an application for Medicare, and meet one of the following conditions: have worked the required amount of time under Social Security, the Railroad Retirement Board (RRB), or as a government employee; or are getting or are eligible for Social Security or RRB benefits; or are the spouse or dependent child of a person who has worked the required amount of time under Social Security, the RRB, or as a government employee; or are getting Social Security or RRB benefits.
Medicare is the primary payer for Part A services for Medicare-enrolled beneficiaries. If a patient receives care from a hospital, a skilled nursing facility, or has home health care, the provider must bill Medicare Part A for all services and then bill the Funds plan as the secondary payer.
Medicare Part B is Medical Insurance. Medicare Part B benefits are processed and paid by the Funds for Fund beneficiaries who are eligible for Medicare. The Funds is the primary payer for Medicare Part B services if the beneficiary has no other group health plan that is primary. Medicare Part B is required to keep the Funds' health services card. If an individual is eligible for but not enrolled in Medicare Part B at the time they are determined to be eligible for benefits from the Funds, the effective date for their health benefit coverage from the Funds will be delayed.
Medicare Advantage (Part C) is an alternative to Parts A and B that bundles several coverage types, including Parts A, B, and usually Part D (prescription drugs).
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UMWA Funds coverage
There are two types of Medicare coverage that UMWA members are required to enroll in when they become eligible: Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Medicare is the primary payer for Part A services, while the Funds act as the primary payer for Part B services if there is no other group health plan that is primary.
Under a special arrangement with Medicare, the Funds process and pay Medicare Part B benefits for Fund beneficiaries who are eligible for Medicare. Most services covered by Medicare are also covered by the Funds, but there are some differences. For example, skilled care in a skilled nursing facility after Medicare's 100 days are used up is covered by the Funds but not Medicare. Certain disposable supplies, such as incontinence products, are also covered by the Funds but not Medicare.
It is important to note that UMWA Funds coverage does not require members to enroll in a Medicare Advantage Plan or a Medicare Part D Prescription Drug Plan. However, if a member decides to cancel their Medicare Part A or Part B coverage, their Funds coverage will be suspended until they reenroll.
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Medicare eligibility
Medicare is a health insurance program for people aged 65 or older. However, individuals below 65 may be eligible for Medicare if they have a disability, End-Stage Renal Disease, or ALS.
There are two types of Medicare coverage: Part A (Hospital Insurance) and Part B (Medical Insurance). Most people don't pay a premium for Part A coverage, often called "premium-free Part A." You won't have to pay a premium for Part A if you meet certain conditions, such as qualifying for or receiving retirement or disability benefits from Social Security or the Railroad Retirement Board. Additionally, if you are under 65 and receive dialysis or a transplant for permanent kidney failure, you may qualify for premium-free Part A.
For Part B coverage, you will have to pay a premium every month, regardless of whether you use any covered services. When you become eligible for Medicare, you are required to enroll in both Part A and Part B.
Some individuals receive Medicare automatically, while others must actively sign up. This depends on whether you start receiving Social Security benefits before turning 65.
Medicare benefits are also offered to retirees of specific programs, such as Railroad workers and United Mine Workers (UMWA). UMWA is traditionally a managed-care plan and may require authorization. If you have UMWA coverage, Medicare is the primary payer for Part A services, and the Funds (UMWA) is the primary payer for Part B services if you have no other group health plan.
For specific questions regarding Medicare eligibility and coverage, it is recommended to refer to the official U.S. government Medicare handbook, "Medicare and You," or contact the provided phone numbers for more information.
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UMWA and Medicare billing
UMWA, or the United Mine Workers of America, is a managed-care plan that provides Medicare benefits to retirees. Medicare is the primary payer for Medicare Part A services for Medicare-enrolled UMWA beneficiaries. The UMWA Funds is the primary payer for Medicare Part B services if the beneficiary has no other group health plan that is primary.
When a patient receives care from a hospital, skilled nursing facility, or home health care, the provider must bill Medicare Part A for all services and then bill the UMWA Funds plan as the secondary payer. The UMWA Funds processes and pays Medicare Part B benefits for eligible beneficiaries.
It is important to note that UMWA Funds does not require beneficiaries to enroll in a Medicare Advantage (Part C) plan or a Medicare Part D Prescription Drug plan. Medicare Advantage Plans are offered by private companies that contract with Medicare to provide Part A and Part B benefits. These plans typically have their own rules for treating and billing patients and may be associated with Medicare replacement plans.
Most services covered by Medicare are also covered by the UMWA Funds. However, there are some differences. For example, the UMWA Funds covers skilled care in a skilled nursing facility after Medicare's 100 days, certain disposable supplies, and routine immunizations. On the other hand, Medicare covers chiropractic services for manual manipulation of a subluxated spine, which is not covered by the UMWA Funds.
For billing questions, doctors can contact the UMWA Funds' Provider Customer Service Unit at 1-888-865-5290.
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Medicare Advantage Plans
There are two main types of Medicare Advantage Plans: HMOs and PPOs. HMOs generally only cover care provided by in-network providers, while PPOs offer access to out-of-network providers at a higher cost. PPOs can be local (serving one or multiple counties) or regional (serving a single state or group of states). Other types of plans include Private Fee-for-Service plans, Medicare Medical Savings Accounts, PACE plans, and non-risk-bearing cost plans, though enrollment in these is relatively low.
In 2023, 49% of Medicare beneficiaries were enrolled in Medicare Advantage Plans, and by 2025, over half of total Medicare enrollment is projected to be in these plans.
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Frequently asked questions
The primary payer is the insurance that pays first. It pays up to the limits of its coverage.
The secondary payer is the insurance that pays second. It pays only if there are costs the primary payer didn't cover.
Yes, Medicare can be the primary payer. If you have Medicare and another health insurance plan, Medicare may be the primary payer, the secondary payer, or may not have any cost-sharing responsibility.
Yes, you can have both UMWA and Medicare. UMWA is traditionally a managed-care plan and Medicare benefits are also sometimes offered to retirees of specific programs, including United Mine Workers of America (UMWA).
The primary and secondary status of your insurance depends on many factors. If you're not sure whether Medicare is your primary or secondary payer, you can check with your employer or private insurer.
