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This text is referenced from California Health Advocates. For any additional information, please visit cahealthadvocates.org. For info in other states, please contact us.
This fact sheet covers nine possible situations for people (age 65 and older) who are eligible for Medicare:
- Coverage while working
- Retirement Plans
- Tricare for Life
- Veterans Affairs System
- Low Income: Medicaid (Medi-Cal)
- Medicare Savings Programs
- Medicare Supplement Insurance: Medigap Policies
- Medicare Select Plans
Medicare does not cover all your health care expenses and has deductibles and costs that you will have to pay. The following are ways to fill the gaps in Medicare:
1. Can you have Medicare insurance coverage after age 65 while you or your spouse is working?
If you are 65 years old or over, and you or your
spouse still works, you may have health care
coverage from your employer. If your employer
has 20 or more employees, your employer must
offer you the same group health plan that is
offered to the other employees. If you choose to
have both the employer´s group health plan and
Medicare, the employer plan will be primary and
pay first. Medicare will be secondary and will
pay only after the employer plan.
Are you entitled to Medicare Insurance coverage if you are younger than 65,
on medicare, and you, your spouse, or a
parent is still working:
People with
disabilities who are on Medicare and who
have group health benefits through a family
member who is employed, are entitled to the
same health benefits as other employees and
dependents if the company has 100 or more
employees. If you choose the employer´s
health plan, it will pay first and Medicare will
pay second.
Can you be eligible for Medicare coverage if you are younger than 65
and have permanent kidney failure:
Some people with kidney failure, known as
End Stage Renal Disease (ESRD), continue to
work and are also eligible for Medicare
coverage. Others are covered by the
employer plan even after they are unable to
work. If you have ESRD and are covered by
an employer group health plan, and you have
Medicare, the employer plan is required to pay
first for 30 months following the effective
date of your Medicare benefits. This is true
regardless of the size of the group and
regardless of whether the person with ESRD
is working or not.
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2. Retirement Plans: Are Medicare plans Medigap plans?
Some people receive health insurance as a
retirement benefit from their employment, their spouse´s employment, or
their parent´s former employer or union. Benefits
and costs vary widely from plan to plan. Some
plans cover costs that are not covered by
Medicare, such as dental and vision benefits.
Others have large deductibles that must be met
before any benefits will be paid. While these
benefits are coordinated with those paid for by
Medicare, these plans are not Medigap plans.
Employers can change the benefits, cost sharing
or premiums for these plans, or drop the plan at
will. Retirees can also lose their benefits if a
former employer files for bankruptcy.
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3. TRICARE For Life (TFL)
TFL is a program that provides coverage to all uniformed service retirees, their spouses, survivors, and other qualified dependents. Beneficiaries must be enrolled in Medicare Parts A and B. There are no premiums or co-payments for Medicare covered services other than the Part B Medicare premium. TFL provides full supplemental medical coverage for all Medicare services and includes prescription drug coverage.
For more information call 1-800-538- 9552 or 1-866-363-5433 or visit the website at tricare.osd.mil./tfl/default.cfm.
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4. Veterans Affairs (VA)
Veterans of any age, except for those who have been dishonorably discharged, may apply for health care called the Uniform Benefits Package at the Department of Veterans Affairs. There are no premiums, and the VA provides hospitalization, primary health care, diagnostic and laboratory services, mental health and substance abuse treatment, home health care, respite care, hospice care, some urgent and limited services outside VA facilities, and prescription drugs. The VA may also provide nursing home care, adult day health care, dental care, and eyeglasses.
The VA encourages enrolled veterans to retain any other health insurance they may have, including Medicare. Veterans with private health insurance or with federally funded coverage through the Department of Defense (Tricare), Medicare or Medicaid/Medi-Cal, may choose to use these sources of coverage in addition to their VA health care benefits. To enroll in the Uniform Benefits Package, apply at any VA health care facility or veterans´ benefit office, or mail in a completed application form.
For more information, call 1-800-827-1000 or 1-877-222- VETS (8387) or visit the VA website va.gov/elig.
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5. Medicaid (known as Medi-Cal in California)
Medi-Cal coverage is available to certain people with low incomes and limited resources. Medi-Cal pays for "medically necessary" health care, including hospitalization, outpatient services, physical therapy, emergency room, doctor visits, nursing home care, adult day health services, eyeglasses, some dental care, hearing aids, ambulance services and certain prescription drugs not covered by Medicare. It also pays your Medicare Part B premiums, and the co-payments and deductibles if you go to providers that accept both Medicare and Medi-Cal. If you are receiving Medi-Cal benefits, you don't need a Medigap policy, and it is illegal for companies to sell you one.
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6. Medicare Savings Programs and Other Low Income Assistance
Several federal programs, such as the Qualified Medicare Beneficiary (QMB) Program, the Specified Low-Income Medicare Beneficiary (SLMB) Program, and the Qualified Individual Program (QI), help people with low incomes pay for Medicare. All of these programs pay the Medicare Part B monthly premiums. QMB also pays for Medicare deductibles and co-payments, and the Medicare Part A premium ($254-$461 per month in 2010) for those who do not qualify to get Part A for free. There are varying income and asset requirements for these programs.
If none of the six options mentioned above are applicable to you, you may want to consider buying a Medigap policy or joining a Medicare Advantage plan. A HICAP counselor can provide information about these options.
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7. Medigap Policies / Medicare Supplement Insurance Policies
Medicare supplement insurance or Medigap policies are sold by private insurance companies. There are 10 modernized plans labeled A through N that pay for part, or all, of Medicare's co-payments and deductibles. Some may also cover other health care costs that Medicare doesn´t pay for, such as foreign travel emergency medical care. Once you buy a Medigap policy, the company cannot change the benefits covered by the plan, and cannot cancel the policy unless you fail to pay the monthly premium. The company can however, at its discretion, increase the premium you must pay.
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8. Medicare SELECT Plans
Medicare SELECT plans are a type of Medicare supplement insurance policy. A Medigap SELECT plan is a combination of a standardized Medigap policy and a Preferred Provider Organization (PPO). PPOs are groups of medical providers, such as hospitals and doctors that have agreed to limit how much they charge members who use the plan´s network.
Medicare SELECT plans supplement Medicare if you are to receive all your care from the plan´s network of providers, the PPO. If you get health care outside of the plan´s network, you may have to pay for most or all of the costs. In California, only a few companies sell Medicare SELECT plans. Once you have purchased a Medicare SELECT policy, the company cannot change the benefits covered by the policy and cannot cancel it unless you fail to pay the monthly premium.
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