Who Pays First: Medicare and Other Health Benefits: Your Guide To
Who Pays First: Medicare and Other Health Benefits: Your Guide To
Who Pays First: Medicare and Other Health Benefits: Your Guide To
What Is Medicare?
Medicare is health insurance for people age 65 or older, under age 65
with certain disabilities, and any age with End-Stage Renal Disease
(permanent kidney failure requiring dialysis or a kidney transplant).
Medicare has
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
• Medicare Part C (combines Part A and Part B coverage)
• Medicare Part D (prescription drug coverage)
Medicare Part A
Medicare Part A helps cover inpatient care in hospitals, including
critical access hospitals. It also covers skilled nursing facility, hospice,
and home health care. You must meet certain conditions to get these
benefits.
Cost: You usually don’t pay a monthly premium for Part A coverage
if you or your spouse paid Medicare taxes while working.
You pay up to $461 (in 2010) each month if you don’t get
Words in premium-free Part A. If you pay a late enrollment penalty, this
red are amount is higher.
defined
on pages
33–34.
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Section 1: The Medicare Program
Medicare Part B
Medicare Part B helps cover medical services like doctors’ services,
outpatient care, and other medical services Medicare Part A doesn’t
cover, if those services are medically necessary. Medicare Part B is
optional. You have to enroll in Part B and pay a monthly premium.
Your monthly premium depends on your income (see chart). Part B
also covers some preventive services.
Part B (Medical Insurance) Monthly Premium
If Your Yearly Income is (in 2008) You pay
File Individual Tax Return File Joint Tax Return
$85,000 or below $170,000 or below $110.50*
$85,001-$107,000 $170,001-$214,000 $154.70
$107,001-$160,000 $214,001-$320,000 $221.00
$160,001-$214,000 $320,001-$428,000 $287.30
Above $214,000 Above $428,000 $353.60
* Most people will continue to pay the 2009 Part B premium of $96.40 in
2010. If you have questions about your Part B premium, call Social
Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
You also pay a Medicare Part B deductible ($155 in 2010) each year
before Medicare starts to pay its share. Medicare premium and
deductible rates may change every year in January.
Medicare Part C
Medicare Advantage Plans (Part C) are another way to get your Medicare
benefits. They combine Part A, Part B, and, sometimes, Part D
(prescription drug) coverage. Medicare Advantage Plans are managed by
private insurance companies approved by Medicare. These plans must
Words in cover medically-necessary services. However, plans can charge different
red are copayments, coinsurance, or deductibles for these services.
defined
Medicare Part D
on pages
33–34. Medicare prescription drug coverage (Part D) is available to everyone
with Medicare. Private companies approved by Medicare provide this
coverage. If you are in Original Medicare, you choose a separate
Medicare Prescription Drug Plan and pay a monthly premium.
See page 4 for more information about Medicare Prescription Drug
2 Coverage. Costs vary by plan.
Section 1: The Medicare Program
3
Section 1: The Medicare Program
4
2
Section 2: Basic Information
5
Section 2: Basic Information
* If your employer participates in a plan that is sponsored by two or more employers, the rules are slightly different.
6
Section 2: Basic Information
Are covered under Entitled to Medicare Medicare pays for Medicare- TRICARE may pay 28– 29
TRICARE and TRICARE covered services. second.
TRICARE pays for services
from a military hospital or
any other federal provider.
Have black lung disease and Entitled to Medicare Federal Black Lung Medicare 29– 30
covered under the Federal and Federal Black Program for services related
Black Lung Program Lung Program to black lung
7
Section 2: Basic Information
Example
Harry is almost 65 and is getting ready to retire and enroll in
Medicare. Harry’s wife, Jane, is 63, and works for a large
company (more than 20 people). Both Harry and Jane have
health insurance coverage through Jane’s employer’s group
health plan. When Harry gets the Initial Enrollment
Questionnaire in the mail from Medicare, he fills it out and
reports that he has insurance through his wife’s employment.
This insurance will pay Harry’s claims first, and Medicare will
pay claims second.
8
Section 2: Basic Information
Who should I call if I have a general question about who pays first?
Words in You should call the benefits administrator at your health insurance plan.
You can also call the Medicare Coordination of Benefits Contractor at
red are 1-800-999-1118. TTY users should call 1-800-318-8782.
defined
on pages
33–34.
9
Section 2: Basic Information
Notes
10
3
Section 3: Medicare and Other Types of Insurance or Coverage
Section 3 includes
Medicare and Group Health Plan Coverage . . 12–14
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Section 3: Medicare and Other Types of Insurance or Coverage
12
Section 3: Medicare and Other Types of Insurance or Coverage
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Section 3: Medicare and Other Types of Insurance or Coverage
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Section 3: Medicare and Other Types of Insurance or Coverage
15
Section 3: Medicare and Other Types of Insurance or Coverage
16
Section 3: Medicare and Other Types of Insurance or Coverage
Example
Mary works full-time for XYZ Company, which has 120
employees. She has large group health plan coverage for herself
and her husband. Her husband has Medicare because of a
disability. Therefore, Mary’s group health plan coverage pays
first for Mary’s husband, and Medicare pays second.
Words in
red are
defined
on pages
33–34.
17
Section 3: Medicare and Other Types of Insurance or Coverage
Example
Bill has Medicare coverage because of ESRD (permanent kidney
failure). He also has group health plan coverage through his
company. Bill’s group health plan coverage will pay first for the
first 30 months after he becomes eligible for Medicare. After 30
months, Medicare pays first.
Words in
red are
defined
on pages
33–34.
18
Section 3: Medicare and Other Types of Insurance or Coverage
19
Section 3: Medicare and Other Types of Insurance or Coverage
Example
Nancy is 69 years old. She’s a passenger in her granddaughter’s
car, and they have an accident. Nancy’s granddaughter has
Personal Injury Protection/Medical Payments (Med Pay) coverage
as part of her automobile insurance. While at the hospital
emergency room, Nancy is asked about available insurance
coverage related to the accident. Nancy tells the hospital that her
granddaughter has Med Pay coverage. Because this insurance pays
regardless of fault, it is considered no-fault insurance. The hospital
bills the no-fault insurance for the emergency room services, and
only bills Medicare if any Medicare-covered services aren’t paid
for by the liability insurance.
20
Section 3: Medicare and Other Types of Insurance or Coverage
Example
Joan is driving her car when someone in another car hits her. Joan
has to go to the hospital. The hospital tries to bill the other driver’s
liability insurer. The insurance company disputes who was at fault
and won’t pay the claim right away. The hospital bills Medicare,
and Medicare makes a conditional payment to the hospital for
health care services that Joan received. Later, when a settlement is
reached with the liability insurer, Joan must make sure that
Medicare gets its money back for the conditional payment.
Words in
red are
defined
on pages
33–34.
21
Section 3: Medicare and Other Types of Insurance or Coverage
22
Section 3: Medicare and Other Types of Insurance or Coverage
Example
Tom was injured at work. He filed a claim for workers’ compensation
insurance. His doctor billed the state workers’ compensation insurance
for payment. Payment wasn’t received in 120 days. Tom’s doctor
billed Medicare and sent a copy of the workers’ compensation claim
with the claim for Medicare payment. Medicare can make a
conditional payment to the doctor for the health care services that
Tom received. When a settlement is reached with the state workers’
compensation agency, Tom must make sure that Medicare gets its
money back for the conditional payment.
How does Medicare get its money back for the conditional payment?
If Medicare makes a conditional payment, and you or your lawyer haven’t
reported your worker’s compensation claim to Medicare, you should call
the Medicare Coordination of Benefits Contractor (COBC) at
1-800-999-1118. TTY users should call 1-800-318-8782.
23
Section 3: Medicare and Other Types of Insurance or Coverage
24
Section 3: Medicare and Other Types of Insurance or Coverage
25
Section 3: Medicare and Other Types of Insurance or Coverage
26
Section 3: Medicare and Other Types of Insurance or Coverage
27
Section 3: Medicare and Other Types of Insurance or Coverage
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Section 3: Medicare and Other Types of Insurance or Coverage
29
Section 3: Medicare and Other Types of Insurance or Coverage
Words in
red are
defined
on pages
33–34.
30
Section 3: Medicare and Other Types of Insurance or Coverage
Words in
red are
defined
on pages
33–34.
31
Section 3: Medicare and Other Types of Insurance or Coverage
32
4
Section 4: Words to Know
33
Section 4: Words to Know
34
5
Section 5: Index
35
Section 5: Index
Pre-existing Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2
Primary Payer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 20
Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 7, 8, 12, 20, 29
Recovery Contractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22, 24
Retiree Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 12–16
State Health Insurance Assistance Program . . . . . . . . . . . . . . . . . . 12, 15, 32
TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 28–29
TRICARE for Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Veterans’ Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7, 26–28
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 22–26
Workers’ Compensation Medicare Set-aside Arrangement . . . . . . . . . 24, 25
“Medicare and Other Health Benefits: Your Guide to Who Pays First” isn’t a legal
document. The official Medicare Program provisions are contained in the relevant
laws, regulations, and rulings.
The information in this booklet was correct when it was posted on www.medicare.gov.
To find out if the booklet is available in print, other formats, or if the information has
been updated, call 1-800-MEDICARE (1-800-633-4227). TTY users should call
1-877-486-2048.
36
Notes
37
Notes
38
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Official Business
Penalty for Private Use, $300