Coverage beyond Medicare

Private insurance and retiree plans

Some people have employer-based coverage or retiree plans in addition to, or instead of, Medicare. These plans can:

• Act as primary coverage before Medicare starts, then wrap around Medicare later.
• Offer additional benefits (vision, dental, hearing, wellness programs).
• Have their own networks, prior authorization rules, and cost-sharing structures.

When someone becomes eligible for Medicare, coordination rules between Medicare and private or retiree coverage can significantly change who pays first and what is covered.

Medigap (supplement) policies

Medigap plans are designed to work with Original Medicare (Parts A and B), not Medicare Advantage. They help pay certain deductibles, copays, and coinsurance amounts that Medicare does not cover.

Key points:

• They do not usually add new types of coverage (for example, they don’t turn Medicare into a long-term care plan).
• They can make medical costs more predictable, especially for frequent users of hospital or outpatient care.
• Rules for when and how you can buy or change Medigap plans vary by state.

Medicaid and long-term care programs

Medicaid is a joint federal and state program with widely varying rules. In many states, it is a primary payer for long-term nursing facility care when someone meets financial and functional criteria.

At a very high level:

• Eligibility is based on income, assets, and medical need, which differ by state.
• There may be “spend down” paths or special rules for spouses still living in the community.
• Some states have home- and community-based programs intended to avoid or delay facility placement.

Because the rules are detailed and state-specific, local legal and benefits professionals are essential if you are seriously exploring Medicaid.

Long-term care insurance

Some people have long-term care insurance policies purchased years earlier. These policies vary widely in:

• What settings they cover (home care, assisted living, nursing facilities).
• Daily or monthly benefit amounts and total benefit periods.
• Elimination periods (how long you pay out-of-pocket before benefits start).

When someone already owns a policy, it is worth reviewing it carefully to understand how it interacts with current needs and other coverage.

How to pull this together for your situation

Instead of trying to memorize every rule, focus on mapping what coverage exists and then asking targeted questions:

• “Which coverage is primary and which is secondary right now?”
• “In our situation, what types of care are typically covered, and what usually isn’t?”
• “Who locally can help us look at Medicaid or other state-specific programs if we reach that point?”

You can then use the Tools page to test how different coverage scenarios would affect your “stay vs. move” planning and monthly costs.