Search this site:

Federal Consumer Information Center Medicare Questions and Federal Consumer Information Center: Medicare - Questions and Answers

Section 1: The Original Medicare Plan (continued)

Q: Are there other types of private insurance I can purchase?

A: The following types of policies are generally limited in coverage and are not substitutes for Medigap insurance or comprehensive health coverage. Benefits under these policies are not designed to fill gaps in your Medicare coverage.

Hospital indemnity insurance pays a fixed cash amount for each day you are hospitalized up to a certain number of days. Some coverage may have added benefits such as surgical benefits or skilled nursing home confinement benefits. Some policies have a maximum number of days or a maximum payment amount.

Specific disease insurance, which is not available in some States, provides benefits for only a single disease, such as cancer, or for a group of specified diseases. The value of such coverage depends on the chance you will get the specific disease or diseases covered. Benefits are usually limited to payment of a fixed amount for each type of treatment. Remember, Medicare and any Medigap policy you have will very likely cover costs associated with any specified diseases you may have.

Long- term care insurance may cover some of the many different services that may include help with daily activities at home, or fill some gaps in the coverage that you and/ or your spouse may need in the future.

If you are shopping for long-term care insurance, find out which types of nursing home and long-term care services are covered by the different policies available. For more information about long- term care insurance, ask for a copy of A Shopper’s Guide to Long- Term Care Insurance from either your State Insurance Department or the

National Association of Insurance Commissioners,
120 W. 12th Street, Suite 1100,
Kansas City, MO 64105- 1925.

You may also get a copy of the Guide to Choosing a Nursing Home from the Health Care Financing Administration by calling 1-800-MEDICARE (1-800-633-2447 or TTY/TDD: 1-877-486-2048 for the hearing and speech impaired).

Q: When would other insurance pay first? (That is, Medicare would be a secondary payer.)

A: If you are age 65 or over, and covered by a group health plan because of current employment or the current employment of a spouse of any age, Medicare is the secondary payer if the employer has 20 or more employees. This means that the plan coverage pays first on your hospital and medical bills. If the plan does not pay all of your expenses, Medicare may pay secondary benefits for Medicare-covered services after the benefits paid by the group health plan.

Medicare is also the secondary payer for people under age 65 who are entitled to Medicare because of disability and are covered by a large group health plan (LGHP) because of their current employment or the current employment of a family member. A LGHP is a plan of, or contributed to by, an employer or employee organization that covers the employees of at least one employer with 100 or more employees. The secondary payer requirement applies to employers, employees, and members of their families covered by large group health coverage or employer and union sponsored health plans. It also applies to those who have LGHP coverage as a self-employed person, business associate of an employer, or as a family member of one of these people. A LGHP must not treat any of these beneficiaries differently because they are disabled and have Medicare.

Medicare is the secondary payer to a group health plan for 30 months for beneficiaries who have Medicare because of End-Stage Renal Disease (ESRD) (permanent kidney failure being treated with dialysis or a transplant). This applies only to those with ESRD, whether you have plan coverage of your own or as a dependent. The group health plan coverage is the primary payer during this period without regard to the size of the employer-based coverage, the number of employees, or whether the individual or a family member is currently employed.

For more information on Medicare secondary payer issues, you may get a copy of the Guide to Health Insurance for People with Medicare from the Health Care Financing Administration by calling 1-800-MEDICARE (1-800-633-4227 or TTY/TDD: 1-877-486-2048 for the speech and hearing impaired).

Q: What is an Advance Beneficiary Notice?

A: An Advance Beneficiary Notice is a written notice that tells you why Medicare probably (or certainly) will not pay for a service. A doctor or supplier might give you this notice before you are given the service. If you still want to get the service, you will be asked to sign an agreement that you will pay for the service yourself if Medicare does not pay for it. Advance Beneficiary Notices are used in the Original Medicare Plan, but not in Medicare managed care plans.

Search this site:

Get the Savvy Consumer Newsletter! (FREE)