Insurance Insight

Here is information about insurance-related issues.

Question:
I am over 65 and retired. My former employer provides insurance for retirees, and. also have Medicare. How does coverage work?

 Answer:
People often sign up for the company's retiree insurance policy because it will cover items Medicare may exclude, such as prescription drugs or routine annual physical examinations. Get copy of the plan's summary of benefits booklet, and see what is offered.

If you have coverage from both, Medicare is usually the primary payer. This means that Medicare pays the bills first, based on its coverage guidelines, and then the corporate coverage kicks in.

Question:
I am over 65 and still working . Do. have to sign up for Medicare, or can get the regular company health insurance?

 Answer:
You have guaranteed right to choose. If your firm has 20 or more workers, and it offers health insurance for them, it must make the same policy available to you. Take a look at the policy, and see how its benefits compare with what you would receive under Medicare. You may decide that the company policy's premiums are too costly and choose not to enroll. Then Medicare will be your sole health-insurance provider.

But suppose you think the company policy is a good one, and you enroll. Now you have both policies: corporate health insurance and Medicare. If you get sick and need to go to the doctor, your group health insurance will be the primary payer.

If it did not cover all the bills, then the doctor, hospital or provider of durable medical equipment should send the bill to Medicare. After reviewing what the company plan paid, Medicare will cover any additional costs up to its approved limits.

Suppose you have. $3,500 bill for medical treatment after a stay in the hospital, and your company insurance pays $2,700, leaving. balance of $800. Medicare reviews the bills and determines that it would pay $3,000 for the same treatment (after you had satisfied the appropriate deductible and co-payment). Medicare will pay $300 -- the difference between the company coverage and its approved fee schedule. Therefore, your out-of-pocket costs will be $500.

One note: This sequence applies to firms with 20 or more workers. If you work for a smaller company with health insurance, then Medicare becomes the primary payer.

Question:
What happens if. fall on the steps of my neighbor's home and have to stay in the hospital for two days?

Answer:
If your neighbor has homeowners' insurance, tell the admitting clerk at the hospital. Your neighbor's liability insurance carrier will be the primary payer, and the hospital should bill the insurance company first. However, it sometimes takes. long time for an insurance company to pay. If there is no payment within 120 days, the hospital or doctor may bill Medicare. You will not have to use your own money to pay the bill.

Question:
I am working and have health insurance, but. want to retire at 64. I won't have any insurance then and will be too young for Medicare. What can I do?

 Answer:
You are protected under a federal law called COBRA (Consolidated Omnibus Budget Reconciliation Act). It is designed exactly for situations like yours. At 64, you may have a hard time affording an individual health insurance policy. And if you have any significant health problems, you might not be able to buy a policy at any price. COBRA gives you the guaranteed right to continue the health coverage for 18 months after you leave the company. But you have to pay the full cost -- both your share of the premium and the share paid by your former employer.

Question:
I am under 65, disabled and covered by Medicare. But. work part time for a company with health insurance. What happens if I have both policies?

 Answer:
The rules are different, depending on the size of the business. If your company has fewer than 100 workers, Medicare is the primary payer.

With 100 or more workers, a company is considered to have a large group health plan. And the company plan is the primary payer.

Question:
I served in the Vietnam War, and have veterans benefits and Medicare . What is the payment situation?

 Answer:
You are entitled to receive treatment either through the Department of Veterans Affairs program or through Medicare. Each time you go to the hospital or visit a doctor, you must decide which program you will be using. Medicare will not pay for the same service if it was already covered by VA benefits. The VA will pay for prescription drugs, which are not covered by Medicare unless they are administered through. durable medical equipment item such as a nebulizer. But the VA will honor a prescription only if it is written by a VA doctor. You can find get more information on VA benefits by calling (877) 222-VETS or by visiting the department's site, www.va.gov