Secondary Payers (Medicare supplements and other secondary payers)
Supplemental coverage can be through private commercial insurance such as a Medigap, employer-sponsored, or other privately purchased plan. Lower income Medicare beneficiaries may have access to supplemental coverage through a state Medicaid program. The amount of the Part B co-insurance paid by the secondary insurance can vary according to the type of supplemental coverage.
Medigap1
Up until May 31, 2010, Medicare beneficiaries may have purchased one of 12 standardized Medigap plans. Beginning June 1, 2010, Medicare beneficiaries had the option to purchase one of 10 standardized Medigap plans. These plans offer consistent benefits regardless of which insurance company the beneficiary purchases coverage from. Of the 10 standardized plans for 2011, 7 plans cover the 20 percent Medicare coinsurance in full, and the other 3 cover a portion of the 20 percent coinsurance. When claims cross over from Medicare to a standard Medigap plan, the Part B co-insurance is paid based on Medicare coverage, rather than imposed tiers or formularies when the service is covered by Medicare as the primary payer. The Medigap plans that are available to disabled and ESRD Medicare patients vary by state.
Medicaid
Medicare beneficiaries may be eligible for secondary coverage through Medicaid, either for full benefits or through special low-income programs such as the Qualified Medicare Beneficiary (QMB) program. These plans may help pay for a portion of or the entire premium or patient cost share that remains after Medicare has paid for covered services. An explanation of the different types of Medicaid and the benefits available to qualifying patients is available in the Medicaid Overview section.
Low-Income Subsidy (LIS)
Medicare beneficiaries who are enrolled in a Part D plan and have limited income and resources may be eligible for the low-income subsidy (LIS or "extra help"), which helps pay for a portion of or the entire premium or patient cost share that remains after the Part D plan has paid for covered drugs.
It is important that you verify coverage and financial responsibilities on a patient-specific basis to understand how plans coordinate benefits. If you need assistance understanding your patients' benefits or determining whether your patients could qualify for additional resources that can help with cost share, call ARS at 1-800-477-6472.
1. Centers for Medicare & Medicaid Services. 2010 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare. Baltimore, MD: US Dept of Health and Human Services; January 2011. CMS Publication No. 02110.
