Types of Plans
There are several types of Medicare plans. It's up to you to decide which services you choose and who administers your benefits (a private health insurance company or the government).
Original Medicare
Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) are often referred to as Original Medicare. If you have Original Medicare, you will receive your benefits through the federal government.
Medicare Advantage Plans
Private insurance companies like Blue Cross Blue Shield of Massachusetts offer Medicare Advantage Plans. By law, insurance providers must offer the same benefits as Original Medicare and can also offer you additional benefits as well. HMOs and PPOs are examples of these private health plans. Some plan options even include Medicare Prescription Drug Coverage (Part D) benefits.
Medigap Policy (Medicare Supplement Insurance)
A Medigap policy is health insurance offered by private insurance companies to fill uncovered costs or "gaps" that Original Medicare doesn't cover.
Part D Prescription Drug Plans
This coverage option can help lower your current prescription drug costs and keep you from having to pay higher costs in the future. These plans are only available through private insurance companies, like us.
How Does Medicare Work With Other Insurance?
If you have Medicare and other health insurance (or coverage), each type of coverage is called a "payer." When there's more than one payer, the "coordination of benefits" rule decides which one pays first. The "primary payer" pays what it owes first and then sends the remainder of what is owed to the "second payer" to pay. In some cases, there may also be a third payer.
Whether Medicare pays first depends on a number of situations.
For example, if you are 65 or older, entitled to Medicare, and you are covered by a group health plan because you or your spouse is still working, the chart below demonstrates when Medicare would pay first.
If you have questions about who pays first, or if you have questions about who pays first, or if your coverage changes, call the benefits coordination & Recovery Center(BCRC) toll-free at 1-855-798-2627. (TTY: 1-855 797 2627)
| Number of Employees | Pay First | Pay Second |
|---|---|---|
| If the employer has 20 or more employees | Group Health Plan | Medicare |
| If the employer has less than 20 employees | Medicare | Group Health Plan |
* If your employer participates in a plan that's sponsored by two or more employers, the rules are slightly different.
How do primary and secondary coverage work together?
The insurance that pays first (primary payer) pays up to the limits of its coverage. Then the secondary payer only pays if there are costs that were not covered by the primary insurer. Keep in mind, the secondary payer (which may be Medicare) may not pay all of the uncovered costs.
If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will pay.
What does "paying first" mean?
When an insurer pays first, it means they have paid the bill up to the limits of the coverage. It doesn't mean the primary payer necessarily paid before the secondary payer. In fact, if the primary payer doesn't pay the claim promptly (usually within 120 days), your doctor or other insurance provider may bill Medicare.
Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should have made. A conditional payment is a payment Medicare makes for services another payer may be responsible for.
Two Options to Getting Your Medicare Coverage
When it comes to health care coverage, you have options. The key is to explore them thoroughly and make the choice that best fits your lifestyle and health needs.
Option 1: Original Medicare + Medigap (Medicare Supplement) + Part D
Part A (Hospital Insurance): No premium for most people
Part B (Medical Insurance): Optional at a standard monthly premium
You can also add to Original Medicare with:
Medigap Policy (Medicare Supplement Insurance)
An optional policy, purchased from private insurance companies to fill in gaps in Original Medicare coverage.
Part D Prescription Drug Coverage
An optional policy, purchased from private insurance companies, which covers costs for prescription drugs. Part D plans are often paired with a Medigap plan for comprehensive coverage across all aspects of your health care.
Option 2: Original Medicare + Part D + More = Medicare Advantage
- Provide Medicare Parts A and B benefits (you must enroll in Parts A and B); possible additional benefits like vision, hearing, and dental.
- Available for purchase from private insurance companies
- Out-of-pocket costs vary by plan types and insurance companies
- Medicare Advantage plans include
- HMO
- PPO
- PFFS
- Some plans include Part D prescription drug coverage
- Your monthly premium equals your Part B premium and Medicare Advantage plan premium
For more information, visit www.medicare.gov and download the Medicare & You brochure, or call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048), 24 hours a day/7 days a week, for details.