Paul Sanchez
If you have more than one insurance policy, it's important to know which one is the primary payer and which is the secondary payer. The primary payer pays up to the limits of its coverage, and the secondary payer covers any remaining costs. Medicare is usually the primary payer, while Medicaid is often the secondary payer. Medicare is the United States' federal health insurance program, with four parts covering specific services, while Medicaid is a public health insurance plan that provides coverage for people who meet certain criteria, such as income guidelines, and is administered by the federal government and individual state agencies. Humana is a private health insurance company that offers Medicare Advantage plans, which provide additional benefits beyond Original Medicare, such as vision, dental, and hearing care.
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What You'll Learn
Medicare and Medicaid eligibility
Medicare and Medicaid are both health insurance programmes, but they have different eligibility criteria and cover different services. Medicare is a federal health insurance programme for people aged 65 and over, and some people under 65 with certain disabilities or conditions. There are four parts to Medicare:
- Part A: covers inpatient care in hospitals, critical access hospitals, skilled nursing facilities, hospice care and some home health care. Most people don't pay a premium for this.
- Part B: covers doctors' services, outpatient care, medical supplies and preventive services. The standard premium is $148.50 per month.
- Part C: Medicare Advantage, provided by private insurance companies, which covers everything in Part A and B, and often includes extra benefits such as vision, hearing and dental care.
- Part D: Prescription Drug Coverage, which everyone with Medicare can access regardless of income.
Medicare eligibility is handled by the Social Security Administration, who can be contacted on 1-800-772-1213. Eligibility usually starts three months before turning 65 and ends three months after turning 65.
Medicaid is a joint federal and state programme that helps cover medical costs for certain low-income people, including families and children, pregnant women, the elderly, and people with disabilities. The rules around eligibility differ in each state, but generally, an individual must meet the state's rules for income and resources, and be a resident of the state. Medicaid covers services that Medicare does not, including nursing home care, personal care services, prescription drugs, eyeglasses, and hearing aids.
Some people are eligible for both Medicare and Medicaid, known as "dual eligibility". In these cases, Medicare is usually the primary payer, with Medicaid covering any remaining costs for items and services it covers.
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Primary and secondary payers
When you have more than one insurance payer, there are rules to determine which insurance company pays first. This is called the coordination of benefits. The primary payer is responsible for paying a claim first and up to the limits of its coverage. The secondary payer then covers the remaining balance. If the secondary payer does not cover the remaining balance, the patient may be responsible for the rest of the costs.
Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility. In other words, another entity has the responsibility for paying before Medicare. When Medicare began in 1966, it was the primary payer for all claims except for those covered by Workers' Compensation, Federal Black Lung benefits, and Veteran’s Administration (VA) benefits. Since 1980, Medicare has been the secondary payer to certain primary plans to shift costs from Medicare to the appropriate private sources of payment.
There are several situations in which Medicare is the primary payer. For example, Medicare is the primary payer for beneficiaries who are not covered by other types of health insurance or coverage. If an individual is 65 or older, is self-employed, and covered by a Group Health Plan (GHP) through their current employment or their spouse's current employment, and the employer has 20 or more employees, then the GHP pays primary and Medicare pays secondary. If an individual is disabled, is covered by a GHP through their own current employment or a family member's current employment, and the employer has 100 or more employees, then the GHP pays primary and Medicare pays secondary.
There are also situations in which Medicare is the secondary payer. For example, if an individual has End-Stage Renal Disease (ESRD), is covered by a GHP, and is in the first 30 months of eligibility for Medicare, then the GHP pays primary and Medicare pays secondary during this 30-month coordination period. If an individual is 65 or older and covered by Medicare and COBRA, then Medicare pays primary and COBRA pays secondary. If an individual is entitled to Medicare and was in an accident or other situation where no-fault or liability insurance is involved, then no-fault or liability insurance pays primary and Medicare pays secondary.
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Humana's role
Humana is a private health insurance company that offers Medicare plans and health insurance coverage. It is ranked highly for customer experience and has a range of Medicare Advantage plans available.
Medicare is the primary payer and usually covers most Medicare-eligible healthcare services. Medicaid is typically the secondary payer and covers any remaining costs for items and services it covers. If an individual is eligible for both Medicare and Medicaid ("dual eligible"), their Medicaid and Medicare plans will work together to provide the best coverage for their needs.
Humana offers Medicare Advantage plans, also known as Part C, which are private insurance plans that provide all of Part A (Hospital Insurance) and Part B (Medical Insurance) coverage. These plans often include extra benefits such as vision, hearing, and dental care, as well as prescription drug coverage (Part D). Humana also provides group dental and vision plans, which are insured, offered, or administered by Humana Insurance Company or its subsidiaries.
In addition to insurance, Humana also provides easy access to ID cards, claims, in-network providers, and drug pricing through its MyHumana online platform.
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Plan options
Medicare Advantage Plans (Part C) are an alternative to Original Medicare, providing Part A (Hospital Insurance) and Part B (Medical Insurance) benefits. These plans are offered by Medicare-approved private companies and often include additional benefits such as drug coverage (Part D). Humana's Medicare Advantage PPO plan offers a wide range of benefits, including $0 copays for preventive care and primary doctor's office visits, and no annual deductible. The plan also provides worldwide emergency coverage and mental health services. Additionally, enrollees are automatically enrolled in the Go365 wellness program, which rewards healthy activities.
Medicaid, on the other hand, is a federal and state program that provides health coverage for low-income individuals and families. Eligibility and enrollment requirements vary by state, and annual redetermination is necessary. Medicaid often serves as a "payer" alongside other insurance coverages, coordinating benefits to ensure individuals receive the necessary care.
Both Humana and Medicaid offer a range of plan options to suit different needs. It is important to review these options and consider factors such as benefits, costs, and availability in your area to make an informed decision about your primary insurance.
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Additional benefits
Humana offers a range of additional benefits to its customers. Firstly, they provide individual dental and vision plans, which are insured or offered by various subsidiaries and affiliates of Humana Inc. These plans are available in different states, including Arizona, New Mexico, and Texas, with some variations in the specific coverage provided.
Secondly, Humana offers Medicare Advantage Plans (Part C), which include all the benefits of Original Medicare Parts A (Hospital Insurance) and B (Medical Insurance). Most of these plans also include prescription drug coverage (Part D), making it convenient for individuals to manage their healthcare needs through a single plan.
Thirdly, for those with chronic health conditions, Humana provides Medicare Special Needs Plans (SNPs). These plans are tailored for individuals eligible for both Medicare and Medicaid and combine the benefits of Original Medicare with prescription drug coverage. SNPs offer specialized care for people with diabetes, cardiovascular disorders, chronic heart failure, and chronic lung disorders, ensuring that they receive comprehensive support for their specific health needs.
Additionally, Humana has a history of providing Commercial and Medicare Advantage health plans, dating back to 1985. They offer a full spectrum of integrated, senior-focused care management programs designed to meet the unique needs of seniors. Moreover, they have a comprehensive suite of health management programs that address the diverse health requirements of their retiree population.
Lastly, Humana's health plans provide flexibility in choosing healthcare providers. Their PPO plans, for example, allow individuals to visit any Medicare-approved doctor who accepts Humana's plan terms. This flexibility ensures that customers can seek medical attention from their preferred healthcare providers within the Humana network.
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Frequently asked questions
Medicare is the United States' federal health insurance program, while Medicaid is a public health insurance plan that is run by both federal and state agencies. Medicare has four parts (A, B, C, and D) that cover specific services, while Medicaid covers medical expenses for eligible people with limited income and resources.
In most cases, Medicare is the primary payer and covers most Medicare-eligible healthcare services. Medicaid is typically the secondary payer and covers any remaining costs for items and services it covers. If you are "dual eligible", Medicare will be your primary plan.
Dual eligibility refers to being eligible for both Medicare and Medicaid. If you are dual eligible, your Medicare and Medicaid plans will work together to provide you with the best coverage for your needs.
