Group Health, Medicare, and Medicaid
Group health insurance
Group coverage is issued as one master policy to the employer or association, with certificates given to participants. Underwriting focuses on the group rather than the individual, and eligibility rules must be objective and nondiscriminatory. A noncontributory plan (employer pays all) usually requires 100% participation; a contributory plan commonly requires about 75%. Group plans typically include a coordination-of-benefits provision, a conversion privilege allowing an insured to buy individual coverage when group coverage ends, and continuation rights under COBRA (generally 18 months, sometimes 29 or 36) for employers with 20 or more employees. HIPAA limits pre-existing condition exclusions and protects portability.
Medicare
Medicare is federal. Part A (hospital) is premium-free with 40 quarters of work; Part B (medical) charges a premium, which is higher for high-income enrollees (IRMAA). Part C is Medicare Advantage, a managed-care alternative delivering Part A and B benefits, often with drug coverage. Part D covers outpatient prescription drugs. The initial enrollment period is the seven months around the 65th birthday (three before, the birthday month, three after); the annual election period is October 15–December 7, and a Medicare Advantage open enrollment runs January 1–March 31. Enrollment can be delayed without penalty while the person has creditable employer coverage.
Medigap and Medicaid
Medigap supplements Original Medicare, cannot include drug coverage, and guarantees issue during a one-time six-month open enrollment. Medicaid is a joint federal-state program for low-income people, with state-set eligibility; dual eligibles qualify for both Medicare and Medicaid.
Rule of thumb
Employer coverage = federal-floor rules; Medicare = age/work-history eligibility; Medicaid = income-based.