Alyssa Lane
If you have a disability, you have several options for health coverage. It is possible to have both private insurance and Medicare at the same time, and a process called coordination of benefits determines which insurance provider pays first. If you have Medicare and other health insurance, each type of coverage is called a payer. The primary payer pays up to the limit of its coverage, then sends the rest of the balance to the secondary payer. If you have a disability, Medicare pays first if your employer has fewer than 100 employees, and your group health plan pays first if your employer has more than 100 employees. If you have Medicaid, you are considered covered under the healthcare law and don't need a Marketplace plan.
| Characteristics | Values |
|---|---|
| Private insurance plans | Offered by private companies |
| Many people get private insurance through a group plan provided by their employers | |
| Public insurance plans | Government-funded |
| Medicare, Medicaid, and Veteran's Affairs benefits are examples of public insurance | |
| 65.6% of Americans have some form of private insurance, while only 36.1% have public insurance | |
| Combining private insurance and Medicare | Possible |
| In certain instances, a process called "coordination of benefits" determines which insurance provider pays first | |
| If you have Medicare and other insurance, each type of coverage is called a "payer" | |
| The "primary payer" pays up to its limit, then sends the rest to the "secondary payer" | |
| Medicaid | If you have a disability, you may qualify for Medicaid coverage |
| If you have Medicare, you're considered covered and don't need a separate Marketplace plan | |
| If you're eligible for Medicaid, your eligibility may continue even after enrolling in Medicare | |
| Medicare | For people 65+ years old, some disabled people under 65, and those with end-stage renal disease |
| Consists of Part A (hospital insurance, often free) and Part B (medical insurance, often paid monthly) | |
| Medicare may make conditional payments if the primary payer doesn't pay promptly | |
| Medicare can't pay for items that workers' compensation will cover | |
| TRICARE provides coverage for active and retired military members and their dependents |
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![Private health insurance : options for reform Subcommittee on Health of the Committee on Ways and Means, U.S. House of Representatives. 1990 [Leather Bound]](https://m.media-amazon.com/images/I/61IX47b4r9L._AC_UY218_.jpg)
What You'll Learn
Medicare and private insurance
Medicare is a public health insurance programme that is government-funded. Private health insurance plans, on the other hand, are offered by private companies and are often provided by employers. It is possible to have both Medicare and private insurance at the same time. This can occur if you have coverage through an employer or your spouse's employer, or if you have COBRA or TRICARE coverage.
When you have both types of insurance, a process called "coordination of benefits" determines which insurance provider pays first. This provider is known as the “primary payer” and pays up to the limits of its coverage. The other provider, known as the "secondary payer", pays for any remaining costs that the primary payer does not cover. However, the secondary payer may not always cover all the remaining costs, in which case you may be responsible for the remaining balance.
The determination of which insurance is the primary payer depends on the type of private insurance and your individual situation. For example, if you are 65 or older and your company has 20 or more employees, your group health plan pays first. However, if your company has fewer than 20 employees, Medicare pays first. Similarly, if you have a disability or ALS and work for a company with 100 or more employees, your group health plan pays first. But if your company has fewer than 100 employees, Medicare becomes the primary payer.
It is important to inform your doctor or healthcare provider about any changes in your insurance or coverage to ensure that your bills are sent to the correct payer and to avoid delays in payment.
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Medicaid and Medicare
If you have both 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". If the secondary payer doesn't cover the remaining balance, the patient may be responsible for the remaining costs. In the case of Medicare and Medicaid, Medicare is typically the primary payer, and Medicaid pays last. However, if a patient is dually eligible, Medicare covers prescription drugs, and Medicaid may still cover some drugs that Medicare does not.
Medication coverage under Medicare and Medicaid can be complex, and it is recommended that patients consult with their doctor and other healthcare providers about any changes in insurance or coverage. It is also important to note that there are ongoing political discussions around cutting Medicaid, which could result in millions losing access to healthcare and food assistance.
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Group health plan payers
Group health plans are a common way for people to obtain health insurance, with 65.6% of Americans having some form of private insurance, often through their employer. When an employer has 100 or more employees, the health plan it offers is called a "large group health plan". Group health plans are considered a “payer” when an individual has multiple types of health coverage. The “primary payer” pays up to the limits of its coverage and then sends the remainder of the balance to the "secondary payer".
If you have Medicare and are also covered by a group health plan, there are rules that determine which insurance provider pays first. If you are 65 or older, and your company has 20 or more employees, your group health plan pays first. If your company has fewer than 20 employees, Medicare pays first. If you have a disability, and your company has 100 or more employees, your group health plan pays first. If your company has fewer than 100 employees, Medicare pays first. If you have ESRD, your group health plan pays first for 30 months, regardless of company size. If you are retired, Medicare pays first, and your retiree coverage pays second.
If you are covered by both TRICARE and Medicare, you must be enrolled in Medicare Part A and Part B to keep your TRICARE drug benefits. If you join a Medicare drug plan, TRICARE will pay second. If you have COBRA and Medicare, the payer order depends on your specific situation. If you are 65 or older, or have a disability, Medicare pays first. If you have ESRD, COBRA pays first.
If you are covered by both Medicare and Veteran's benefits, you can choose which benefits to use when you get healthcare.
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Disability benefits
Social Security Disability Insurance (SSDI):
SSDI is a federal program administered by the Social Security Administration (SSA). It provides monthly benefits to individuals who are unable to work due to a disability. In 2022, the average monthly benefit for disabled workers in the SSDI program was nearly $1,500. SSDI beneficiaries often have to endure a five-month waiting period for payments to begin, followed by a two-year waiting period for Medicare eligibility, known as the "Medicare waiting period."
Supplemental Security Income (SSI):
SSI is another federal program managed by the SSA. It provides monthly payments to individuals with disabilities, particularly those with limited income and resources. In 2022, the average monthly benefit for disabled beneficiaries in the SSI program was nearly $650. SSI beneficiaries in most states automatically qualify for and receive Medicaid coverage.
Medicaid and Medicare:
Medicaid and Medicare are public health insurance programs that provide coverage for individuals with disabilities. Medicaid is available to SSI recipients in most states, while SSDI beneficiaries may qualify for Medicare after receiving disability benefits for at least two years. Some individuals may even qualify for both programs, known as dual-eligible individuals. Additionally, individuals with disabilities can explore private health insurance options through the Health Insurance Marketplace or their employers.
It is important to note that the eligibility criteria and benefits vary between states for SSI and Medicaid. While most SSI recipients automatically qualify for Medicaid, some states have more restrictive rules or require a separate application process. Therefore, it is advisable to check the specific guidelines for your state to understand the disability benefits available and the application process.
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Health coverage options for people with disabilities
If you have a disability, there are several health coverage options available to you. Firstly, it is important to note that if you currently have Medicaid or Medicare, you are considered covered under healthcare law and do not need additional coverage. However, if you are seeking health coverage, there are a few options to explore.
One option is to apply for Medicaid, a public health insurance program that is government-funded. Many states have expanded their Medicaid programs to cover all adults whose income falls below a certain threshold, including people with disabilities. You can apply for Medicaid through the Health Insurance Marketplace, also known as Healthcare.gov, to find out if you qualify based on your income or disability status.
Another option is to explore private health insurance plans. These plans are offered by private companies, and many people obtain this coverage through their employer or their spouse's employer. If you have a pre-existing condition or special healthcare needs, it is important to ensure that your chosen plan covers these from the first day. Private plans can work in conjunction with Medicare in certain instances, a process known as ""coordination of benefits," which determines which insurance provider pays first.
Additionally, if you receive Social Security Disability Income (SSDI), you may be eligible for Medicare or are in a 24-month waiting period before it starts. During this waiting period, you may be able to obtain Medicaid coverage or keep your Marketplace plan as supplemental insurance when you transition to Medicare.
It is worth noting that some health insurance plans, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans, require the use of in-network providers. If Medicare pays first in this situation and you choose an out-of-network provider, your Medicare coverage may not apply.
Overall, individuals with disabilities have a range of health coverage options, including Medicaid, Medicare, private health insurance, and SSDI-related coverage. It is important to assess your personal circumstances, income, and specific healthcare needs when deciding which option best suits your requirements.
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Frequently asked questions
Private group insurance is provided by an employer, whereas disability Medicaid is for those with a disability and is funded by the government.
Yes, you can have both private insurance and Medicare at the same time. In this case, a process called "coordination of benefits" determines which insurance provider pays first.
The "primary payer" pays up to the limits of its coverage, 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.
Medicaid is a government-funded health insurance program for people with disabilities. It covers treatment for pre-existing conditions from the first day of coverage.
Yes, if you are disabled and working, you can keep your employer's insurance without giving up your Medigap policy.
