CDISNM Blog
In addition to Medicare coverage, many seniors carry group insurance through an employer or a spouse’s employer. If you need medical services, which insurance pays first?
Different healthcare plans are called “payers”. You will have a primary payer (the one who pays first) and a secondary payer (the one who pays second). Who pays first and who pays second depends on many things, including, how many employees an employer has if you are retired or still working, and whether or not you are covered under a spouse’s group plan.
If the Employer Has 20 or More Employees, a Group Health Plan Usually Pays First
For companies with over 20 employees, group health coverage typically pays before Medicare. If you are over 65, have Medicare, and are enrolled in coverage through work, your group plan usually pays first. When employer benefits do not cover the entire cost of medical care, the balance is sent to Medicare. Your out-of-pocket costs will vary based on how much of the remaining balance Medicare pays.
If the Employer Has Less Than 20 Employees, Medicare Usually Pays First
If you receive your health benefits through an employer with less than 20 employees, Medicare typically pays first. However, there are instances where your group coverage might pay first if your employer joined with other employers to form a multi-employer plan, and at least 1 employer in the group has 20 or more employees, then group coverage pays first.
If You Receive Retiree Coverage Through a Former Employer, Medicare Usually Pays First
Generally, if you are retired and receiving retiree coverage through a former employer, Medicare pays first and group coverage pays second. However, if you are retired, your spouse is not retired and you are covered under his or her policy with 20 or more employees, group coverage pays first and Medicare pays second.
Additional Things to Consider
Receiving care outside an employer plan’s network can be tricky. In many cases, receiving medical care outside of an employer plan’s network can cause both group coverage and Medicare not to pay. Be careful when considering out-of-network care. Check with your employer plan to ensure they will still pay. If you do not take your employer’s coverage, coverage through a spouse will pay before Medicare. If you choose not to take employer-offered health care through your work, Medicare will pay for approved services. However, if you have coverage through a spouse, or if your spouse’s employer has over 20 employees, Medicare will not pay first.
If you are receiving COBRA, Medicare typically pays first. Even if you had COBRA benefits before being enrolled in Medicare, Medicare Pays first. If you have Medicare and are 65 or older, and receive COBRA benefits after enrolling in Medicare, Medicare pays first. Even with a secondary payer, you may have out-of-pocket expenses. The primary payer (whether it’s Medicare or group coverage) doesn’t always pay the full balance owed from medical care. Unfortunately, the secondary payer may not cover all of the remaining costs.
If you choose to delay Part B, group coverage may not be paid until you join Part B. The secondary payer only pays if there are costs the primary insurer doesn’t cover. If you don’t have a primary payer because you chose to delay Part B, group insurance may not pay until you enroll in Part B (to have a primary payer).
References:
https://www.medicare.gov/supplement-other-insurance/how-medicare-works-with-other-insurance/who-pays-first/which-insurance-pays.html
https://www.medicare.gov/supplement-other-insurance/how-medicare-works-with-other-insurance/how-medicare-works-with-other-insurance.html
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CDISNM Blog
Preventive services are designed to prevent you from getting sick or ill. Typically, they include exams, lab tests, shots, and screenings that help detect problems early on when treatment is most successful. In addition, preventive care includes counseling that can help seniors make more informed decisions about lifestyle choices as they age. If you’re looking to learn what preventive and screening services Medicare covers, the following information can help.
Preventive Services
For seniors enrolled in Medicare, a key benefit is preventive services or those exams, tests, and screenings that provide a snapshot into the state of your health and well-being. Staying current with all of the required exams and screenings is the most effective way to ensure you stay healthy and strong. In addition to a “Welcome to Medicare” visit, seniors can expect to receive an annual wellness visit along with routine glaucoma tests, bone density tests, flu shots, and even tests for identifying sexually transmitted diseases.
Covered Services
One-time “Welcome to Medicare” preventive visit
Glaucoma tests
Bone mass measurements
Sexually transmitted infection testing
Yearly wellness visit
Flu, Hepatitis B, and Pneumococcal shots
Cancer, diabetes, and cardiovascular disease affect thousands of seniors each year, and Medicare offers regular screenings as part of preventive care benefits. Treatment is most successful when illness is detected early, which is why screening services are prioritized as an important preventive benefit.
Covered Screening Services
Multiple cancers
Hepatitis C
Diabetes
Depression
Obesity
Alcohol
Cardiovascular
HIV
Finally, Medicare recognizes that seniors often struggle with making healthy lifestyle choices. Original Medicare provides a variety of counseling services designed to help interested seniors learn about important lifestyle choices. Important information on alcohol use, smoking, and even tips on how to prepare nutritious meals are provided as part of Medicare preventive counseling services. By giving seniors the tools and resources they need to make more informed decisions, Medicare encourages health and wellness for well-deserving seniors.
Covered Counseling Services
Alcohol
Obesity
Sexually transmitted infections
Tobacco use cessation
Nutrition therapy
References:
https://www.medicare.gov/coverage/preventive-and-screening-services.html
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CDISNM Blog
Most people have enrolled automatically in Original Medicare (Part A and Part B) as they approach the age of 65 with coverage start dates based on birthday month. For those who need to enroll manually, effective coverage dates could be earlier or later, depending on the situation. Knowing exactly when your coverage starts can help you make the right decisions about your medical care.
Automatic Enrollment
Here’s the good news: most people have enrolled in Original Medicare automatically, and receive a red, white, and blue Medicare card by mail approximately 3 months before turning 65. In this case, Medicare benefits begin on the first day of your birthday month. For example, if you were born on July 24, July 18, or even July 31, your benefits begin on July 1. There is one exception. For those born on the 1st of the month, benefits begin on the 1st day of the month before the birthday month. For example, if you were born on December 1, your benefits begin on November 1.
If You Sign Up Manually During Your Initial Enrollment
In the event you have not enrolled automatically and choose to enroll in Medicare yourself, effective coverage dates vary based on the month you sign up. If you sign up during your Initial Enrollment Period (the 7 months beginning 3 months before your 65th birthday and ending 3 months after your 65th birthday) effective start dates are shown below.
If you sign up for Medicare:
The same month you turn 65, coverage begins 1 month after you sign up.
1 month after you turn 65, coverage begins 2 months after you sign up.
2 months after you turn 65, coverage begins 3 months after you sign up.
3 months after you turn 65, coverage begins 3 months after you sign up.
If You Sign Up Manually After Your Initial Enrollment Period
You may enroll in premium-free Part A (most people are eligible) anytime during or after your Initial Enrollment Period starts with coverage start dates based on when you sign up. However, if you do not qualify for free Part A, and need to buy it or need to sign up for Part B, and miss your Initial Enrollment Period, you may have to wait until General Enrollment Period, Jan 1-Mar 31, with coverage starting on July 1.
References:
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-coverage-starts/when-coverage-starts.html
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-how-to-sign-up-for-part-a-and-part-b.html#collapse-5769
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-sign-up-parts-a-and-b/when-sign-up-parts-a-and-html
https://www.medicare.gov/your-medicare-costs/part-a-costs/part-a-costs.html
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CDISNM Blog
As a Medicare recipient, you can travel anywhere in the United States and still be covered, as long as you use doctors and hospitals that accept Medicare. However, if you travel outside of the United States, your Medicare coverage is limited. But what about Medicare Supplement Insurance? How does your plan work when you travel in the U.S. and out of the country?
Coverage In the U.S.
Like Original Medicare, Medicare Supplement plans typically do not require that you use specific doctors or hospitals from a network. Medical care you receive anywhere in the U.S. is usually covered. However, there are exceptions. If you have a Medicare Select plan with a defined network, different rules apply, and you may not be able to use your insurance outside of your plan’s network. In addition, some plans with benefits above Original Medicare, like vision and dental, may make these benefits available only in the state where you bought the plan.
Coverage Outside of the U.S.
Depending on the Medicare Supplement plan you choose, you may have coverage for services or medical supplies you need while out of the country. Currently, plans G and N offer foreign travel emergency health care coverage when traveling outside of the United States. With any plan offering foreign travel benefits, care must begin sometime within the first 60 days of your trip, and cannot be covered by Original Medicare. After you meet a $250 deductible, your Medigap plan will pay 80 percent of the billed charges. Note: Foreign travel emergency care provided by plans have a lifetime limit of $50,000.
Resources:
https://www.medicare.gov/supplement-other-insurance/medigap-and-travel/medigap-and-travel.html
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CDISNM Blog
Here’s some good news: if you’re turning 65 soon, you’ll also be eligible to join Medicare – a federally funded program that provides hospital and medical insurance to older Americans. Transitioning to Medicare for the first time can be confusing and you’re not alone if you have a few questions. Here’s a great resource to get you started—important tips and things to think about as you plan for Medicare coverage.
Enrollment In Medicare Is Automatic
If you’re worried about how to sign up for Medicare before your birthday, don’t be. For most seniors, enrollment in Original Medicare (Part A and Part B) is automatic. As long as you receive Social Security or Railroad Retirement benefits, you don’t need to do anything at all and your Medicare card will be sent to you by mail. Expect to receive your card 3 months before you turn 65, with benefits beginning on the first day of your birthday month. If you do not receive retirement benefits, you may need to enroll in Medicare manually through the Social Security Administration or Railroad Retirement Board.
Accepting or Opting Out of Part B
While Part A (hospital insurance) is free for most people, Part B (medical insurance) is not. A monthly premium will be deducted from your Social Security check each month. In 2024, the standard Part B premium is $174.70 (or higher depending on income). However, most people who receive Social Security benefits will pay less than this amount. If you are still working, covered through an employer or a spouse’s employer, you do not need to keep Part B coverage or pay for it. You can choose to opt out of Part B coverage on the back of your membership card.
Important tip: If you opt out of Part B coverage, and do not have comparable coverage through an employer or spouse, you may end up paying a late enrollment penalty when you decide to join.
Initial Enrollment Period
When you first become eligible for Medicare, you enter what is called your Initial Enrollment Period. This is a 7-month period of time beginning 3 months before your birthday month, and extending 3 months after your birthday month. For example, if you were born in July, your Initial Enrollment Period would be April 1 through October 31. This is the time to enroll in Medicare (for those not enrolled automatically) or enhance coverage with additional benefits.
Important tip: If you’re looking to add additional coverage to Original Medicare, your Initial Enrollment Period is the time to do it. If you delay, you may have to wait until the General Enrollment Period (Jan 1- Mar 31) of the following year and may also be charged a late enrollment penalty.
Adding Benefits
Original Medicare covers much of your health care needs, but it doesn’t cover everything. It’s up to you to decide if you want to enhance coverage with extra benefits and how. Understanding your options will make it easier to choose the perfect complement to your Medicare coverage. There are only two ways to receive Medicare: through Original Medicare or Medicare Advantage (Part C). Original Medicare provides Part A and Part B. Medicare Advantage Provides Part A, Part B, and extra benefits. Medicare Supplement (Medigap) insurance and Prescription Drug coverage (Part D) may be added to Original Medicare for additional benefits.
Medicare Supplement – Medigap helps pay the out-of-pocket expenses associated with Medicare, like deductibles, coinsurance, and copays. While there are no benefits for dental, vision, or prescription drugs, some plans provide coverage while traveling outside of the country. You are responsible for paying a monthly premium for Medigap coverage as well as your Part B premium.
Medicare Advantage – Part C extends Original Medicare by delivering all of your Part A, Part B, and additional benefits from one plan. Dental, vision, and prescription drugs are often covered. If you join a Medicare Advantage plan, you’re still enrolled in Medicare, you simply enhance coverage with extra benefits. You are responsible for paying a monthly premium for Medicare Advantage as well as your Part B premium.
Prescription Drug Coverage – Part D Original Medicare does not include benefits for prescription drugs. If you wish to add coverage, there are only two ways to do it: join a standalone Part D plan, or join a Medicare Advantage plan that already includes prescription drug benefits.
Important tip: you cannot combine Medicare Supplement and Medicare Advantage benefits. If you’re looking to extend benefits beyond Original Medicare, you need to decide which makes the most sense for your specific needs—extra medical benefits or help with expenses.
References:
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-sign-up-parts-a-and-b/when-sign-up-parts-a-and-b.html
https://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html
Cost of Part B: https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html
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