When you have other health insurance, like employer group health coverage, there are rules that decide whether Medicare or your other health insurance pays first. These rules are as follows:

Medicare pays first if you have retiree insurance (insurance from former employment).

Your group health plan pays first if you are 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has 20 or more employees.

Medicare pays first if you are 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has less than 20 employees.

Your group health plan pays first if you are under 65 and disabled, have group health plan coverage based on your or a family member’s current employment, and the employer has 100 or more employees.

Medicare pays first if you are under 65 and disabled, have group health plan coverage based on your or a family member’s current employment, and the employer has less than 100 employees.

If you have ESRD (End Stage Regal Disease) your group health plan will pay first for the first 30 months after you become eligible to enroll in Medicare. Medicare will pay first after this 30 month period.

In some cases, your employer may join with other employers or unions to form a multiple employer plan. If this happens, the size of the largest employer/union determines whether Medicare pays first or second.

Some important facts to remember regarding other health insurance and Medicare include the following:

  • The insurance that pays first (primary payer) pays up to the limits of its coverage.
  • The one that pays second (secondary payer) only pays if there are costs the primary insurer did not cover.
  • The secondary payer (which may be Medicare) may not pay all of the uncovered costs.
  • If your employer insurance is the secondary payer, you may need to enroll in Part B before your insurance will pay.

Medicare may pay second if you’re in an accident or have a workers’ compensation case in which other insurance covers your injury or you’re suing another entity for medical expenses. In these situations you or your lawyer should tell Medicare as soon as possible. These types of insurance usually pay first for services related to each type:

  • No-fault insurance (including automobile insurance)
  • Liability (including automobile and self-insurance)
  • Black lung benefits
  • Workers’ compensation

Medicaid and TRICARE never pay first for services that are covered by Medicare. They only pay after Medicare, employer group health plans, and/or Medicare Supplement Insurances have paid.

 

Medicare Pathways, Inc.

Visit our Medicare News Blog