Maximizing Benefits: Navigating Dual Coverage with Medicare and Private Insurance
Medicare vs Primary Insurance Who Gets Billed First
Key Take Aways
Commercial insurance for a Medicare insured person is not always necessary.
MSP (Medicare Secondary Payer) know who to bill for different health situations
HSA (Health Savings Account) is not allowed once you apply for Medicare insurance.
Always check costs of average by Medicare vs commercial insurance in decision-making of appropriate method for insurance coverage
Primary insurance is always so confusing. What is primary insurance and how does that affect me? Why is Medicare always secondary insurance?
If you are a Medicare recipient and your spouse has commercial insurance coverage for the family that includes you, then your spouse’s insurance is primary or the 1st insurance billed for any care that you receive. Doctors and hospitals all use the same rule.
Medicare will never be primary unless it is the only coverage that you have for healthcare. When you enter a facility, they are required by law to ask you the questions on the MSP or Medicare Secondary Payer questionnaire. You can review the questions at on the CMS.Gov Website.
The reason that providers are always checking on the details of medical coverage is because Medicare is designed for non-working people. Medicare, whether for disability or for retirement, is a form of healthcare that is for retired non-working individuals. Basically, all commercial insurance coverage by a spouse, or benefit coverage from the following will place Medicare in a secondary coverage situation.
Watch out if you are involved in a medical situation that include any of the below criteria:
Black Lung disease fund/benefit or research program,
ESRD where coverage is from a research program that covers costs,
Motor vehicle accident where the automobile insurance company is responsible for medical care,
Workman’s Comp for injuries sustained while at work,
Homeowner insurance if you are injured in your home or someone else’s home,
Injuries sustained through the military should be covered by VA.
Its very important that you have the required information to give to the facility or provider regarding additional coverage for any of the above scenarios. Name, Date of accident or initial diagnosis for research or grant program studies, date of accident, name of insurance company, policy number, contact number.
Medicare, when used as a secondary payor, will cover costs associated to an Outpatient or Inpatient visit after the primary insurance pays. Then when the facility sends Medicare the claim details with the remaining non-paid charges, they will then pay based on their criteria for items based on diagnosis codes, and procedure codes and other items that are usual and customary to the event. But, it’s possible that you could still have a remaining balance post Medicare payment.
If you are Medicare age and have applied for Medicare, ask yourself this question:
Why would you want to be covered by commercial insurance from your spouse and pay the premium that is probably high? Medicare A is free!
Is there a benefit to having double coverage? Not really. Once Medicare deductible is met you will have 20% coinsurance amount per visit that you are required to pay. This is not what the hospital charged but what Medicare says the usual and customary amount is that they recognize to pay. The payment by Medicare is drastically less than what is charged, and so you would pay 20% of that amount as your copay. The yearly deductible is $248 dollars, once paid you will be responsible for the copay and 20%
Part B, which costs money, changes yearly. The amount is taken out of your social security check, or you can have it set to come out of another funding source. $ 174.80 is the monthly fee for Part B coverage. You will have a copay per visit of approved services plus 20% of Medicare usually and customary payment.
Example Emergency room visit 99283 Level 3 average charge is $1737.40. Medicare says that they will pay $245.03 for this procedure and the minimum unadjusted copay by you would be $49.01. 20% would come to $13.00.
As you ponder whether to spend the monthly commercial insurance premium amount for a Medicare insured person always look at actual charge costs and what would Medicare say you would be responsible for. There could be great savings not being on the commercial insurance.
HAS are no longer allowed for a Medicare insured person, but if your spouse is insured with a commercial insurance and is eligible for an HSA, think about putting that unnecessary premium amount into the HSA and build the account. To cover the copay and 20% amount that would be applied to the Part AB insured.
It’s important to review all guidelines in your 2024 Medicare manual noted below. The guidelines are translated into multiple languages.
