Identifying Your Loved One’s Insurance

I often encounter caregivers who have questions on their loved one’s insurance policy. Many times individuals over the age of 65 have not only primary policies, but often times have secondary or supplemental policies as well.

Knowing what these policies are and how they work together is key in making sure your loved one is accessing the correct benefits, services, and Providers. Below I’ve outlined some of the most common types of insurance we encounter for individuals over the age of 65.

Medicare

Traditional Medicare is a federal program that offers health coverage to individuals starting at age 65 and individuals under the age of 65 who have specific illnesses, such as end-stage renal disease. Traditional Medicare consists of Part A coverage, Part B coverage, and Part D coverage.

Part A: covers inpatient services (like a hospital stay)

Part B: covers outpatient services (like a visit to your doctor)

Part D: helps cover prescription drugs

When an individual enrolls in Traditional Medicare, they choose if they want to enroll in all or some of Medicare A, B, and/or D.

Medicare Advantage

There is also something called Medicare part C, or Medicare Advantage (Managed Care) plans. Medicare Advantage plans combine Medicare Part A and Medicare Part B into one plan that is offered by a private insurance company. An example of this type of plan would be Aetna Medicare, Humana Medicare, United Healthcare Medicare and within these plans are PPO policies, HMO policies, Private Fee for Service policies, Special Needs Plans, Dual Special Needs Plans, and so on.

The type of policy (PPO, HMO, etc.) determines things like patient responsibility, in network providers and whether or not a referral is required for specialists, among other things. In addition, Medicare Advantage plans offer added benefits such as prescription drug coverage and routine dental, vision, and hearing care.

Medicaid

Traditional Medicaid is a state and federal program that offers health coverage to individuals who have low income, and just like Medicare, Medicaid has managed plans. CareSource Medicaid, Buckeye Medicaid, and Amerigroup Medicaid being examples. Individuals who qualify for both Medicare and Medicaid are what is called “dual eligible.” Medicare serves as primary in this instance with Medicaid as Secondary.

Supplemental or Medigap

Supplemental policies are also provided through private insurance companies and do not provide full medical coverage. The purpose of these plans is to help cover costs such as co-pays, deductibles, and co-insurance.

Some individuals choose to have multiple policies, and some may still be working and have commercial insurance available through their employer. In general, the order in which the plans are processed is Commercial insurance, Medicare/Medicare Advantage, and Medicaid. (a supplemental policy would follow a Commercial or Medicare policy and is typically not carried with a Medicaid policy). If you have questions on which policy is primary, you can always contact member services and request a coordination of benefits.

Understanding where to begin is a great first step. Once you’re able to identify the order in which Providers will bill the insurance plans your loved one has, it’s also helpful to have an understanding of what the benefit is for a particular service. Each insurance company has a User Guide or Member handbook that is typically accessible on their website and is good to have available for when specific scenarios arise. And as always, never hesitate to ask questions of your loved one’s care team.

By Breanna Boysel, LPN