Primary insurance is the first payer of a claim. Secondary insurance covers the balance due after the first-payer payment, based on the insurer's guidelines. Supplemental insurance is purchased to cover costs that primary and secondary insurance do not cover, such as deductible and coinsurance amounts.
When a beneficiary has more than one insurance plan, the coordination of benefits clause prohibits collecting more than 100 percent of the charges.
Medicare Part A covers inpatient hospital care, skilled nursing facility care, and home health, respite, and hospice care. Services covered under Medicare Part A are measured in benefit periods. A benefit period begins when a patient first receives Medicare-covered inpatient hospital care and ends when that patient has been discharged from the hospital or SNF for sixty consecutive days. Beneficiaries have unlimited benefit periods but are responsible for certain deductibles.
Medicare Part B covers physicians' visits and procedures as well as supplies. For Original Medicare Plan (OMP) beneficiaries, Medicare pays 80 percent of approved charges after the deductible is met, and the patient or a secondary payer pays the remaining 20 percent. For people who enroll in one of the other Medicare plans, such as the Medicare managed care plans, other payment rules apply. Medicare managed care plans, called Medicare Advantage plans, make up Medicare Part C. Medicare Part D provides voluntary Medicare prescription drug plans that are open to people who are eligible for Medicare.
The Medicare Secondary Payer program controls Medicare benefits when Medicare beneficiaries are covered by other plans. A claim is sent first to the primary payer and then to Medicare with the remittance advice.
Medicaid is an entitlement program that pays for the health care needs of individuals and families with low incomes and few resources. The program is jointly funded by the federal government and state governments. Individuals who apply for Medicaid benefits must meet minimum federal requirements and any additional requirements of the state in which they live. To receive federal matching funds, states must cover certain services, including inpatient and outpatient hospital services and emergency services.
TRICARE is the Department of Defense health insurance plan for military personnel and their families. All military treatment facilities, including hospitals and clinics, are part of the TRICARE system. TRICARE also contracts with civilian facilities and physicians to provide more extensive services to beneficiaries. TRICARE plans include Standard, Prime, Extra, Reserve Select, and TRICARE for Life.
CHAMPVA is the government's health insurance program for veterans with 100 percent service-related disabilities and their families. The Department of Veterans Affairs (VA) is responsible for determining eligibility for the CHAMPVA program. CHAMPVA provides coverage for most medically necessary services, including inpatient services, room and board, hospital services, surgical procedures, physician services, anesthesia, and blood and blood products.
Workers' compensation provides employees who are injured while on the job with a means of receiving compensation for their injuries, and it protects employers against liability for employees' injuries. Workers' compensation insurance covers injuries, illnesses, and job-related deaths.
