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Medicare Eligibility vs. Entitlement
Individual Policies
People often mix up these two terms when discussing Medicare. The
difference between the two is:
Being
eligible
means a patient is qualified for Medicare, meets
one of the conditions for coverage and would receive it if they
applied.
Being
entitled
means a patient is qualified for Medicare, meets
one of the conditions for coverage, has applied and a Medicare
ID number was issued. Coverage is active.
We learned in
All About Insurance
that if a patient has an individual
policy, Medicare will always be primary. Sometimes when verifying
coverage, an insurance representative will mention “individual” when
discussing benefits. In order for us to determine the possibility of a
COB, it is important for us to ask questions to clarify during the call:
Is this an
Individual
plan that is privately purchased and not
through an EGHP? (in which case Medicare would always be
primary)
OR
They are calling it
Individual
because the policy holder has no
spouse or dependents on the plan. In this case, it is truly a
group health plan (EGHP), and there could be a possibility of a
COB.