As the age of the working class continues to increase, many individuals who are eligible for Medicare are still receiving commercial insurance coverage through their employers. Consequently, many of these individuals defer taking advantage of Medicare benefits until well after their 65th birthday. However, there is much confusion surrounding the rules and regulations of having both commercial insurance and Medicare. Indeed, many of my eligible patients were unaware Medicare benefits were even an option if they already had private commercial coverage. Additionally, most had little knowledge of how to find information on ways to obtain both policies.

There are several potential benefits to having both Medicare coverage and commercial insurance, including additional coverage for deductibles and copays, as well as payments for tests which may not be covered under traditional commercial insurance policies. However, the real benefit will often depend on whether Medicare is the patient’s primary or secondary overage, which is generally determined by the number of people employed by the company they work for.

Separated into 4

parts: A, B, C and D

Medicare Part A: Refers to coverage which includes inpatient hospital care, treatment at a skilled nursing facility, hospice care, laboratory testing, surgery and some home health care services. Surprisingly, there is “no cost” to have Part A. Thus, for individuals with large deductibles under their commercial plan, Part A Medicare can help save a significant amount of money should they require hospitalization or home care services. However, once an individual takes Part A, they are no longer eligible to participate in any health saving accounts (if offered by their employer). It is therefore recommended that most patients with commercial insurance apply for Part A, regardless of policy coverage.

Medicare Part B: This coverage includes doctor and other health care provider services, outpatient care, durable medical equipment, home health care and some preventive services. There is a cost for Part B insurance (average cost is about $2,000 a year). However, if a patient has a high deductible with their commercial plan, this can be a small price to pay for additional coverage. Medicare Part B will often cover deductibles, copays and services not always covered as part of a commercial plan. However, Medicare Part B, in general, will not cover services not covered under the Medicare program.

Medicare Part C, also known as Medicare Advantage, allows the patient to assign their benefits to an approved private health insurance company. Benefits often include medical and prescription coverage. However, patients may be restricted with respect to their selection of physicians and may also be limited to a list of approved medications covered. This coverage often includes a copay for most medical care.

Medicare Part D includes medication and prescription coverage benefits. This coverage generally costs the patient about $1,500 dollars per year, but will vary depending on income. Some drugs may not be covered and copays for medications do apply.

According to Franca Shillington, vice president at Brown & Brown of Connecticut in Rocky Hill, “If you are eligible for Medicare because you are 65 or older, your employer’s commercial insurance policy will be primary if you (or your spouse) are currently working and there are 20 or more employees working at the company you (or your spouse) work for. If the company you work for has less than 20 employees, Medicare will be your primary insurance policy and the commercial plan will be secondary. Therefore, you will need to apply for both Part A and Part B of Medicare. If you are eligible for Medicare because of a disability, your employer insurance is primary for you (and your spouse) unless the company you work for has less than 100 employees.”

Franca said you need to make sure you ask your employer if their plan can be used in conjunction with Part D. “You cannot use both types of coverage for the same prescription at the same time. Also be aware that some employer coverages often do not work with Part D.”

Explaining and understanding your choices regarding the various Medicare programs is obviously quite complicated. Kelly Poulin, practice administrator at Soundview Medical Associates in Norwalk, said, “As more and more patients aged 65 and older are continuing to be in the work force, it is no longer an automatic ‘assumption’ that these patients will have Medicare Part B/supplement as their health insurance.”

Poulin recommends patients discuss with their HR administrator or insurance broker the options available for them, as well as determining what the best coverage is for them and at the best cost.

“The Medicare maze is quite confusing, even for people like me that deal with insurances on a daily basis. With all the Advantage plans on the market now, there are just so many choices that have to be looked into. In the past, most doctors took all insurances; that is no longer the case.”

She said patients need to be informed on all the changes taking place within the insurance industry and should check with their current providers to verify they take the new insurance.

Fortunately, there are seminars and websites dedicated to reviewing the different plans and requirements, restrictions and penalties.

For more information, speak with your physician’s office, visit Medicare.Gov or call 800-Medicare. Don’t miss out on entitled benefits and the opportunity to potentially reduce your health care costs.

Dr. Michael Schwartz is board certified in internal medicine and is affiliated with Soundview Medical Associates, with a private practice in Darien. For comments or questions, visit his website at drmichaelbschwartz.com.