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Health Line
2 days ago
- Business
- Health Line
Medicare and Private Insurance: Can You Have Both?
If you're covered under an employer-provided plan, COBRA, or TRICARE, you can have both Medicare and private insurance. If you have both, the guidelines determine which provider pays for your healthcare services first. Health insurance covers many medical expenses. Generally speaking, there are two basic types of health insurance: Private: These health insurance plans are offered by private companies. Many people get private health insurance through a group plan provided by their employers. Public: Public health insurance plans are government-funded. One example of a public health insurance program is Medicare. Others include Medicaid and Veterans Affairs (VA) benefits. According to a 2024 report from the U.S. Census Bureau, 65.4% of Americans had some form of private health insurance in 2023. Only 36.3% had public health insurance, including 18.9% enrolled in Medicare. In certain instances, private health insurance and Medicare can be combined. How does private insurance work with Medicare? It is possible to have both private insurance and Medicare at the same time. When you have both, a process called 'coordination of benefits' determines which insurance provider pays first. This provider is called the primary payer. Once the payment order is determined, coverage works like this: The primary payer pays for any covered services until the coverage limit has been reached. The secondary payer pays for costs that the primary payer doesn't cover. However, it may not cover all costs. The provider who is the primary payer can depend on the type of private insurance you have and your individual situation. In some cases, Medicare may be the primary payer, while in others, it may be the secondary payer. Did you know? Private insurance companies manage some parts of Medicare, including: Medicare Advantage (Part C) Medicare Part D (prescription drug coverage) Medicare supplement insurance (Medigap) While these plans can be considered private insurance, companies that offer them must be approved by Medicare and agree to follow its rules. Because of this, they're still considered part of the Medicare program. What other types of coverage can you have with Medicare? There are several different situations when you may have private insurance and Medicare at the same time. This can happen if you have: Coverage through an employer: When you're eligible for Medicare, you may still have private insurance through your employer. Coverage under your spouse's private health insurance: You can have Medicare and also be covered on a group plan provided by your spouse's employer. COBRA: COBRA allows you to temporarily keep private insurance coverage after your employment ends. You'll also keep your coverage if you're on your spouse's private insurance and their employment ends. TRICARE: TRICARE provides coverage for active and retired members of the military and their dependents. You can have both TRICARE and Medicare if you: are age 65 or over and enrolled in Medicare Part B have a disability, end stage renal disease (ESRD), or amyotrophic lateral sclerosis (ALS) and are enrolled in both Medicare Part A and Part B have Medicare and are a dependent of an active duty service member with TRICARE Who pays first for your services and medications? Whether Medicare or your private insurance pays first depends on the specific circumstances. You have private insurance coverage through your employer or a spouse's employer When you're eligible for Medicare, you can still have private insurance coverage provided by an employer. Generally speaking, you're eligible for Medicare when you: are age 65 or older have a qualifying disability receive a diagnosis of ESRD or ALS How Medicare works with your group plan's coverage depends on your particular situation, such as: If you're 65 or older: In companies with 20 or more employees, your group health plan pays first. In companies with fewer than 20 employees, Medicare pays first. If you have a disability or ALS: In companies with 100 or more employees, your group health plan pays first. When a company has fewer than 100 employees, Medicare pays first. If you have ESRD: Your group health plan pays first during a 30-month coordination period. This is regardless of the company's number of employees or whether you're retired. Your company may offer you coverage under a group plan after you retire. This is called retiree coverage. In this case, Medicare pays first, and your retiree coverage pays second. Some health insurance plans, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans, require using in-network providers. If this is the case with your group health plan and it pays first, you may not be covered by Medicare if you choose to use an out-of-network provider. You have COBRA If you have both Medicare and COBRA, the provider that pays first depends on your specific situation, such as: You have TRICARE If you have TRICARE, the provider that pays first depends on whether or not you're on active duty: If you're on active duty: TRICARE pays first for any services covered by Medicare. TRICARE also covers Medicare deductibles, coinsurance costs, and any services covered by TRICARE but not Medicare. If you're not on active duty: Medicare pays first. TRICARE can pay second if you have TRICARE for Life coverage. What if I have additional questions about coverage? Working with both private insurance and Medicare can be a complicated process. If you have questions or concerns about what's covered and which provider pays first, you can reach out to several sources, including: Medicare: You can contact Medicare using its general contact information or by contacting its Benefits Coordination and Recovery Center directly at 800-633-4227 (TTY: 877-486-2048). Social Security Administration (SSA): Contacting the SSA at 800-772-1213 can help you get more information on Medicare eligibility and enrollment. State Health Insurance Assistance Program (SHIP): Each state has its own SHIP, which can help with any specific questions about Medicare. United States Department of Labor: If your employment has ended, you can contact the Department of Labor to learn more about COBRA coverage at 866-487-2365. TRICARE: Contacting TRICARE directly at 866-773-0404 may be beneficial when navigating coverage alongside Medicare. The takeaway In some situations, you can have both private insurance and Medicare, such as if you're covered under private insurance through an employer. When you have private insurance and Medicare, one provider will pay for healthcare services first, and the second may potentially cover the remaining costs. This depends on your situation and the type of private insurance you have. If you have questions about how Medicare works with private insurance, don't hesitate to contact Medicare, the SSA, or your local SHIP for assistance.
Health Line
23-05-2025
- Health
- Health Line
Medicare Part C Costs
Medicare Part C (Medicare Advantage) plans are provided by private insurance companies, which means that cost varies by provider, type of plan, and location. Original Medicare (Part A and Part B) and Medicare Part C (Medicare Advantage) are different insurance options with different costs. Medicare Part C might be a good option if you're eligible for Original Medicare but want additional coverage for prescription drugs and other services. Several factors determine Medicare Part C costs, such as: premiums deductibles copayments coinsurance These amounts can range from $0 to hundreds for monthly premiums and yearly deductibles. Most of your Medicare Part C costs will be determined by your chosen plan. However, your lifestyle and financial situation can also have an effect on your costs. Read on for everything you need to know about Part C-associated costs. Deductibles and Premiums While some Part C plans don't have a monthly premium, others do. According to the Centers for Medicaid & Medicare (CMS), the average monthly premium for Part C plans is around $17.00 in 2025. Even with a zero-premium Medicare Advantage plan, you may still owe the Part B premium. That said, some Part C plans may cover your Part B premium. In addition, Medicare Part C plans have a plan deductible and a drug deductible if the plan includes drug coverage. As with premiums, some plans may offer a $0 plan deductible. When the deductible is greater than zero, you'll need to meet this amount first before your plan will offer coverage. Once it does, your plan usually covers a certain percentage of the cost; the rest comes from your pocket. as copayments or coinsurance. Managing Part C costs One of the first things you can do to manage your Medicare Part C costs is to read through the following annual notices from your plan: evidence of coverage (EOC) annual notice of change (ANOC) These notices can help you determine exactly what costs you'll pay out of pocket for your plan and any price changes that will take effect the following year. Other factors affecting costs While Original Medicare covers services nationwide, most Medicare Advantage plans are location-based. If you travel often, you may find yourself stuck with out-of-town medical bills. Other factors that can affect costs include: Plan type: Your plan can also impact how much your Medicare Part C plan may cost. For example, if you're on an HMO or PPO plan but choose to visit an out-of-network provider, this can increase your costs. Spending limit: All Part C plans have an out-of-pocket maximum. This amount varies, but according to one 2021 study, the average out-of-pocket maximum for Part C plans was $5,000. Extra benefits: Many Part C plans offer additional benefits to Original Medicare. For example, in 2025, over 97% of Medicare Advantage plans include dental, hearing, and vision coverage, though extra costs may apply for specialized services like dentures or specific lenses. Income limits Your yearly gross income can also factor into how much you'll pay for your Medicare Part C costs. For people with a lack of income or resources, there are programs that can help lower their Medicare costs. These are called Medicare Savings Programs (MSPs). The federal government funds these programs, but Medicaid administers them in each state. These programs are: Medicare Part C plans have different costs. Your costs may vary depending on your coverage, plan type, and whether you receive additional financial assistance. Below is a small sample of Medicare Part C plan costs from major insurance providers in cities around the United States: Plan City Monthly premium Health deductible, drug deductible Primary doctor copay Specialist copay Out-of-pocket max Anthem Select (HMO-POS) Los Angeles, CA $0 $0 $0 in network $0 in network $800 in network Cigna Preferred Medicare (HMO) Denver, CO $0 $0 $0 $25 per visit $3,550 in network Humana Choice H5216-006 (PPO) Dane, WI $37 •$0 •$250 $0 in network $45 in network per visit •$4,900 in network •$10,100 in and out of network Humana Gold Plus H0028-042 (HMO) Harris, TX $0 •$0 •$300 $0 $20 $3,450 in network Aetna Medicare Value Plus (PPO) Nashville, TN $11 •$0 •$250 •$0 in network •$10 out of network •$35 in network •$45 out of network •$6,750 in network, •$7,750 in and out of network Kaiser Permanente Medicare Advantage Standard MD (HMO-POS) Baltimore, MD $21 $0 •$5 in network •$0 to 25 out of network •$25 in network •$0 to 50 out of network $6,900 in network The estimates above are for 2025 and are only a sampling of the many plan options offered in each area. For a more personal estimate of Medicare Part C plan costs based on your individual healthcare situation, visit this plan finder tool and enter your ZIP code to compare plans near you. Is Medicare Advantage more expensive than Original Medicare? While it may seem that Medicare Advantage plans cost more than Original Medicare, they can actually help reduce medical expenses. A 2017 study that compared Medicare Advantage to Original Medicare found that physician costs were lower for people who were enrolled in Medicare Advantage plans. In addition, Medicare Advantage plan beneficiaries saved more money on things like medical equipment and lab tests. How do I pay my Part C bill? Most companies offering Medicare Part C plans have various ways to pay your premium. These options include: online bill payment automatic withdrawal from your bank account automatic withdrawal from your Social Security or Railroad Retirement Board benefits check check or money order Help paying for Medicare If you're having trouble paying your Medicare Part C costs, there are resources that can help: Medicaid: This program helps people with low-income pay for medical costs. Medicare savings program (MSP): This benefit helps Medicare beneficiaries with low-income pay plan costs, such as premiums and copayments. Supplemental Social Security: Some individuals can apply for Supplemental Social Security benefits, which are monthly payments that help pay for Medicare costs. PACE: This program can help you get coordinated care within your local community. Extra Help: If you meet certain income and resource limitations, you may qualify for this Medicare program, called Extra Help, to pay for prescription drug costs, premiums, deductibles, and more. The takeaway Medicare Part C (Medicare Advantage) is a great coverage option for Medicare beneficiaries seeking additional coverage. Your Medicare Part C costs include premiums, deductibles, copayments, and coinsurance. Your costs will also be determined based on your plan type, how often you need medical services, and what type of doctors you see. If you're age 65 or older or have certain disabilities, you're eligible to apply for Medicare. Visit the Social Security Administration website for more information on how to apply and enroll. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Health Line
12-05-2025
- Health
- Health Line
When Should I Sign Up for Medicare Part D?
There are set times during the year, and during a person's life, when they may sign up for Medicare Part D. In some situations, not signing up for Part D when you are first eligible can lead to future penalties. Medicare Part D is prescription drug coverage. A person can purchase a Part D plan when they become eligible for Medicare and have either Part A or Part B coverage. Medicare-approved private insurance companies offer Part D plans. There are two general options for Part D coverage: Stand-alone Part D plans: A person with Part A or Part B can sign up for a stand-alone Part D plan in addition to their Original Medicare coverage. Bundled drug coverage: A person can sign up for a Medicare Advantage plan that bundles Part D coverage with their hospital insurance and medical insurance. If you have a Medicare Advantage plan that does not include Part D, you cannot sign up for a stand-alone Part D plan. Doing so would disenroll you from your Medicare Advantage plan. In this article, we discuss when you can enroll in Part D and the potential penalty for not enrolling. Part D enrollment periods You can only sign up for Medicare coverage, including Part D coverage, during specific periods throughout the year. Initial enrollment period (IEP) The first opportunity you'll have to join a Part D plan is during your IEP. This is a 7-month window that begins 3 months before you first qualify for Medicare. A person will only have one IEP during their lifetime unless they become eligible for Medicare before the age of 65 years due to a disability or chronic health condition. To join a Part D plan during the IEP, you will need to have either Part A or Part B coverage. The IEP is the best time for most people to sign up for a Part D plan. If you choose not to enroll during this time, you may face a late enrollment penalty later. Open enrollment period (OEP) The OEP is an annual Medicare enrollment period that runs from October 15 to December 7. During the OEP, Medicare beneficiaries can make many types of changes to their coverage. A person with Original Medicare can join a stand-alone Part D plan, switch Part D plans, or drop their Part D coverage. A person could also switch from Original Medicare to a Medicare Advantage plan that includes Part D coverage. Alternatively, people with Medicare Advantage can switch to Original Medicare. Medicare Advantage open enrollment period (MA OEP) The MA OEP runs from January 1 to March 31. During this time, a person with Medicare Advantage can switch to a new plan or return to Original Medicare. If they choose to do the latter, they can also sign up for a Part D plan. Special enrollment period (SEP) The last type of enrollment period during which a person can sign up for Part D plan is called a SEP. The timing of SEPs varies. People can qualify for an SEP when they experience a life event that affects their insurance coverage. For example, if a person has health insurance through an employer when they turn 65 years old, they will qualify for an SEP when they lose their employer-sponsored insurance. Depending on the situation, a person can typically sign up for Part D during an SEP. The length of time they'll have to do so will vary based on their individual circumstances. When does Part D coverage begin? If you sign up for Part D during the IEP, your coverage will begin either when your Part A or Part B coverage starts or on the first day of the month after the insurance carrier receives your request. It depends on when you sign up. If you sign up for a new Part D plan — or a Medicare Advantage plan that includes drug coverage — during the OEP, your coverage will begin on January 1 of the following year. If you return to Original Medicare during the MA OEP and sign up for a Part D plan, your coverage will begin at the start of the month after the insurance carrier receives your request. What happens if you don't sign up for Medicare Part D? If you don't sign up for Part D when you first become eligible, you may face penalties later on when you do go to enroll. For every month that you go without Part D coverage, you incur a 1% penalty based on the national base beneficiary premium. In 2025, this base monthly premium is $36.78. The penalty gets added to your Part D monthly premium. Here's an example: If you chose not to enroll in Part D when you turned 65 years old, and you decided to enroll in a plan when you turned 67 years old, you would have to pay a 24% penalty each month (because you went without coverage for 24 months). This works out to about $8.82, based on the base premium of $36.78. This is a permanent penalty that you will pay for as long as you have Part D coverage. You can avoid the late enrollment penalty if you have creditable drug coverage from another source in place of Part D, such as through an employer-sponsored health plan or the Department of Veterans Affairs. Summary The best time to sign up for Part D to avoid paying penalties is during the initial enrollment period (IEP) when you first become eligible for Medicare. If you miss the initial enrollment period, you can also sign up for Part D during the open enrollment period (OEP), which is from October 15 to December 7 each year. However, if you have drug coverage from another source, you will not have to pay a Part D late enrollment penalty.
Health Line
09-05-2025
- Health
- Health Line
Your Guide to Medicare Part D Tiering
Medicare Part D covers prescription drugs. Oftentimes, plans place drugs into tiers to help beneficiaries save money. Medicare Part D plans are provided by Medicare-approved private insurance companies. People with Original Medicare (Part A and Part B) can purchase stand-alone Part D plans. Most Medicare Advantage plans include prescription drug coverage (Part D). Each Part D plan has a drug list (formulary) of the medications it covers. The insurance company may divide these medications into tiers to help reduce costs. Each company can set its own tiers in any way it sees fit. Generally, prescriptions in lower tiers will cost you less. Glossary of common Medicare terms Out-of-pocket cost: This is the amount you pay for care when Medicare doesn't pay the full cost or offer coverage. It includes premiums, deductibles, coinsurance, and copayments. Premium: This is the monthly amount you pay for Medicare coverage. Deductible: This is the annual amount you must spend out of pocket before Medicare begins to cover services and treatments. Coinsurance: This is the percentage of treatment costs you're responsible for paying out of pocket. With Medicare Part B, you typically pay 20%. Copayment: This is a fixed dollar amount you pay when receiving certain treatments or services. With Medicare, this often applies to prescription medications. Medicare Part D generic tier Generic drugs are copies of brand-name drugs. However, they are the same in all the following ways: safety strength dosage form quality route of administration intended use performance characteristics The makers of generic drugs must prove to the Food and Drug Administration (FDA) that their product works in the same way as the brand-name version. Some Part D insurance providers may refer to the generic tier as 'tier 1.' Generic medications tend to be in the lowest tiers and typically cost less than brand-name drugs. Cost sharing Costs may vary by plan, pharmacy, and area. According to the nonprofit KFF, the median out-of-pocket cost for generic drugs in 2025 is $0 for preferred generics and $5 for all other generics. Medicare Part D preferred brands tier Preferred brand drugs are medications that may not have generic equivalents. These drugs may have been on the market for quite some time and are widely accepted. They may also be particular brands on an insurance provider's formulary that it encourages people to use. The provider may do this by offering these medications at a lower copay than similar ones. Some insurance providers may refer to this as ' tier 2.' Prescriptions in this tier tend to have a slightly higher copay than those in the generic tier (tier 1). Cost sharing According to KFF, the median copayment for preferred brand drugs in 2025 is $47. However, preferred brand drugs may have a coinsurance payment instead. If this is the case, the median coinsurance amount is 20% to 24% of the total cost. Medicare Part D non-preferred drugs tier Non-preferred drugs are either brand-name or generic medications that are not listed in the preferred tier in an insurance provider's formulary. These medications may be newer to the market. Typically, medications in the non-preferred tier have higher copayments or coinsurance costs. Some insurance providers may refer to this as ' tier 3.' If your doctor or other healthcare professional prescribes a non-preferred brand-name drug for you, ask them if there is a generic drug available. It is possible that the generic drug may be covered under the lower tier. Cost sharing According to KFF, 43% of people with a Part D plan included in their Medicare Advantage plan pay a median copayment of $100 for non-preferred prescriptions. People with stand-alone Part D plans pay a median coinsurance rate of 40% of the total cost. »Learn more: Generic vs. brand-name drugs Medicare Part D specialty drugs tier Prescriptions may be put into a specialty drug tier because they: have a high cost require special handling treat complex conditions Medications in this tier typically have the highest copayments or coinsurance costs. Cost sharing KFF notes that the median coinsurance cost for specialty tier drugs in 2025 is 25% to 30% of the total cost. Other Part D costs Premium: Part D plans may have a monthly premium that you are responsible for paying, in addition to the Part B premium of $185. Deductible: Deductibles vary by plan. However, in 2025, a plan's deductible cannot exceed $590. Once your out-of-pocket costs reach $2,000, you automatically enter catastrophic coverage. This means you will pay nothing for your prescriptions for the rest of the year.
