了解哪个保险计划先付款

在笔记本电脑上付账的混血人
JGI/Jamie Grill/Getty图片

Why would someone want to have more than one insurance plan?这取决于你问谁。您可能需要额外的保险,以确保您获得所需的所有医疗服务。医疗保险和其他保险公司,另一方面,拥有另一个既得利益。如果你有多个健康计划,他们可以把支付责任转移到另一方身上。

Don't worry.Someone is going to foot the bill,只要每个人都按计划走,不应该是你。你需要了解谁先付钱,谁先付钱,如果有人,会支付剩下的所有费用。这就是医疗保险第二付款人发挥作用的地方。

为什么你可能想要的不仅仅是医疗保险

Medicare provides health care for more than 56.8 million Americans,但这并不意味着它必须涵盖他们所需要的一切。Consider these common items that Medicare leaves you to pay for out of pocket:

This is not an exhaustive list,当然,但难怪有些人追求其他医疗保险来填补这一空白。While there is the option of Medicare Supplement Plans,亦称为Medigap计划,to help cover Medicare's out of pocket costs (复印机,共同保险,and deductibles),these plans do not actually add additional health benefits to your coverage.相反,many people turn to other insurance like employer-sponsored health plans,军事利益,和退休人员福利,以获得他们需要的保险。

医疗保险和雇主赞助的健康计划

社会保障金的退休年龄过去是65岁,the sameage that you become eligible for Medicare.这一切在1983年发生了变化,当时国会通过了一项立法,根据你的生日来增加退休年龄。For people born between 1943 and 1954,退休年龄现在是66岁。对于1960年以后出生的人,退休年龄逐渐增加到最高67岁。提前退休将导致你从社会保险中得到较少的报酬。

The end result is that many people are working longer to maximize their retirement funds.Working gives them access to health care through their employers that they may choose to continue alone,continue while also signing up for Medicare,或者取消并替换为医疗保险。

你的雇主赞助的健康计划可以涵盖你的配偶和家属,whereas Medicare covers you alone.这些计划也可能包括医疗保险不包括的服务。如果您有资格Special Enrollment Period,you may be able to defer enrolling in Medicare without facing迟罚when you finally do sign up.这可以为你节省相当多的钱,因为你不必为两个不同的计划支付保险费。

When you have both Medicare and an employer-sponsored health plan,只有在某些情况下,医疗保险才会优先支付。The decision is based on your age,whether you have end-stage renal disease (ESRD) or anotherdisability,有多少人为你的雇主工作。

如果你不符合医疗保险优先支付的标准,你的雇主赞助的健康计划将被收取费用。他们不支付的费用将被计入医疗保险。Medicare will pay for healthcare services that it would normally cover as long as it sees them as medically necessary.

医疗保险首先支付

Medicare will pay second

If you are 65 years or older -AND- your employer has less than 20 full-time employees

如果你的残疾不是ESRD,而且你的雇主有不到100名全职雇员

如果您有ESRD,您30个月的ESRD协调期已经结束。

如果你65岁或以上,而且你的雇主有20多名全职雇员

如果你65岁或65岁以上——而且——你都是自雇的,并且被另一个拥有超过20名全职雇员的雇主雇佣。

If you have a disability that is not ESRD - AND- your employer has more than 100 full-time employees

如果您有ESRD-和-您在ESRD的30个月协调期内

医疗保险和眼镜蛇

由于1985年的综合预算协调法(COBRA),你可以在离职后继续你的雇主赞助的健康计划。法律要求20名或以上全职雇员的雇主在一段时间内继续提供健康计划的使用权,通常18个月,after your job ends by way of termination or a layoff.持续时间眼镜蛇覆盖率如果满足某些条件,可延长至36个月。

Medicare and COBRA have a tricky relationship.如果你在参加医疗保险时已经有了眼镜蛇,您的COBRA保险可能会在您参加医疗保险之日结束。如果你有资格申请眼镜蛇医疗保险,您可以注册COBRA。

If you have COBRA and become Medicare-eligible during that time,你有一个重要的决定要做。Enrolling in Medicare means you will lose your COBRA benefits for yourself,尽管你可以继续为你的配偶和家属提供保险。如果你选择推迟参加医疗保险,请注意,当您最终注册时,您将面临迟到处罚。COBRA benefits do not qualify you for a Special Enrollment Period with Medicare.

医疗保险首先支付 Medicare will pay second

You are 65 years or older.

You have a disability that is not ESRD

您30个月的ESRD协调期已经结束

您在ESRD的30个月协调期内

Medicare and Worker's Compensation

Worker's compensation works a bit differently than does your employer-sponsored health plan.你和你的雇主之间的州授权协议规定,只要他们支付你的任何工伤医疗费用,你就不会起诉他们。当你接受工人的补偿福利时,你不能为那次伤害寻求惩罚性赔偿。If you decline those benefits,你可以起诉要求损害赔偿,比如疼痛和痛苦。

鉴于你为雇主赞助的健康计划支付保费,worker's compensation premiums are paid for by your employer.你不需要付出任何代价。After an injury,you place a claim and an evaluation takes place to determine whether or not your injury was a consequence of your workplace environment.

这可能是因为工人的赔偿否定了你的索赔,或者只是部分地根据预先存在的条件.例如,如果你有慢性背痛but your back pain gets worse after an injury,it may become difficult to determine how responsible your employer was for your symptoms.Medicare steps in at this stage to make first payments.

工人赔偿金可以在您的医疗费用发生时偿还,也可以提供一次性解决方案。其中一些资金可用于工人补偿医疗保险预留安排(wcmsaa)。an arrangement intended to reserve funds for future treatment of any injuries that result in long-term complications.Medicare will not pay until funds in the WCMSAA are exhausted.

医疗保险首先支付 Medicare will pay second

Your claim is denied by worker's compensation.

您的索赔仅部分包含在工人赔偿金中,这是由于先前存在的条件造成的。

你的索赔包含在工人赔偿中。

医疗保险和军事健康福利

If you are a veteran,现役军人,或是一名退休的制服服务人员,您可能有权从退伍军人管理局(VA)或一个名为Tricare的计划中获得健康福利。These benefits coordinate with Medicare in a unique way.

First and foremost,VA benefitswill only cover care received in a VA-authorized facility.

第二,医疗保险不会支付VA福利支付的医疗费用,反之亦然。There is not an issue of primary versus secondary payer here.

第三,Tricare和Medicare协同工作。Medicare acts as the primary payer for Medicare-covered services and TRICARE covers any Medicare deductibles or coinsurance amount that relates to those services.如果医疗保险不包括服务,Tricare将作为主要付款人。

根据你得到的护理,可以同时让医疗保险和tricare作为主要付款人!

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Article Sources
  • 医疗保险和其他健康福利:谁先付款的指南。医疗保险和医疗补助服务中心。https://www.medicare.gov/pubs/pdf/02179-medicare-coordination-benefits-payer.pdf.
  • 医疗保险登记仪表盘。医疗保险和医疗补助中心服务网站。https://www.cms.gov/research statistics data and systems/statistics trends and reports/dashboard/medicare enrollment/enrollment%20dashboard.html.2016年7月更新。
  • 医疗保险第二付款人。Centers for Medicare and Medicaid Services website.https://www.cms.gov/medicare/coordination-of-benefits-and-recovery/coordination-of-benefits-and-recovery-overview/medicare-secondary-payer/medicare-secondary-payer.html.1月30日更新,2014.
  • Workers' Compensation Medicare Set Aside Arrangements.Centers for Medicare and Medicaid Services website.https://www.cms.gov/medicare/coordination-of-benefits-and-recovery/workers-compensation-medicare-set-aside-arrangements/wcmsa-overview.html.4月18日更新,2016。