Medicare is always primary if it is your only form of coverage. when you enter another form of coverage in the picture, there is a default coordination of benefits. the coordination of benefits will determine which form of coverage is primary and which form of coverage is secondary.
primary coverage will pay first and secondary coverage will pay second. Next, we’ll go over scenarios when Medicare is primary and when Medicare is secondary.
group coverage through a small employer
If your employer has fewer than 20 employees, Medicare will be your primary coverage and the employer’s coverage will be your secondary coverage. If you don’t sign up for Part B, your employer’s coverage won’t pay its share of your medical claims. that’s why it’s so important to sign up for medicare before you’re eligible to do so.
Also, employer coverage is not creditable. therefore, you will incur late enrollment penalties if you don’t sign up for part b when you’re first eligible. this also applies to a spouse in the group plan.
Also, consider how much you’re paying for employer coverage. Most of the time, Medicare costs much less in monthly premiums. Compare both options side by side to see if making Medicare your primary coverage will save you money.
cobra
There are situations where you will have Medicare and collect at the same time. Most of the time, Medicare will be primary and Cobra will be secondary. The exception to this is if your group coverage has special rules that determine the primary payer.
It’s not often that cash is the best option for a person who is eligible for Medicare. this is because cobra is more expensive than medicare. once you enroll in medicare, you can cancel your cobra coverage.
Another key thing to know is that cobra is not creditable coverage. if you are eligible for medicare and don’t sign up, you will incur late enrollment penalties as charges are not considered as good as medicare. You must enroll in Medicare within the first eight months you have Cobra, even if your Cobra coverage is active for more than eight months.
coverage for retirees
When your employer group insurance continues to provide health insurance after you retire, you are receiving retiree coverage. In this scenario, Medicare is primary and its convergence of retirees is secondary. Retiree coverage will often include prescription drug coverage. If this is the case for you, you probably don’t need to join a Part D prescription drug plan.
under 65 and disabled with employer group coverage
if you are under age 65, eligible for medicare due to disability, and have employer group coverage through a small or medium-sized employer with fewer than 100 employees. Medicare will be your primary payer, while your employer’s coverage is secondary.
care for life
When military retirees and their spouses become eligible for medicare, they become eligible for tricare for life. For any care you get in a non-military facility, Medicare pays first. That’s why you should sign up for Part A and Part B when you’re eligible.
however, tfl includes good drug coverage. therefore, you do not need to enroll in part d. Some TFL beneficiaries choose to enroll in a Medicare Advantage plan because of the additional benefits they may have. these additional benefits may include dental and vision coverage. In addition, TFL will help cover some of the out-of-pocket costs that come with Medicare Advantage plans.
end stage renal disease
Individuals diagnosed with ESRD will maintain their current employer’s primary coverage for the first 30 months. After 30 months, they will automatically switch to Medicare as their primary coverage. this rule also applies to cobra & retiree insurance.
if you receive medicare because of esrd and have a successful kidney transplant, your medicare eligibility will end after 36 months. If you are eligible for Medicare because of your age or disability, you will still be enrolled in Medicare even after your kidney transplant.
medication
Medicaid is a state-administered federal assistance program that helps low-income Americans. When you become eligible for Medicare and you are also eligible for Medicaid, you are dual eligible. When you are dual eligible for both Medicare and Medicaid, Medicare is your primary payer. Medicaid won’t pay until Medicare pays first.
if you are dual eligible and need help paying for part b and part d costs, you may qualify for a medicare savings program to help with these costs. always make sure your provider accepts both medicare and medicare before seeking care.
group coverage through a larger employer
Whether you have group insurance through the company you work for or your spouse’s employer, Medicare is your secondary coverage when the employer has more than 20 employees. Some Medicare beneficiaries will choose to delay their enrollment in Part B if their group coverage is cheaper. However, most of the time, after evaluating their coverage, they find that Medicare will cost less and provide better coverage if they allow Medicare to be their primary coverage.
Under 65 and Disabled with Major Employer Group Coverage
If you’re under age 65, eligible for Medicare due to disability, and have employer group coverage through an employer with more than 100 employees, Medicare will be your secondary payer.
trike
tricare pays first for medicare-approved services in a civilian facility if you’re on active duty, medicare will pay second. Medicare does not cover treatment provided by a military hospital or a federal health care provider.
end stage renal disease
medicare will be your secondary coverage if you are diagnosed with esrd, have employer group coverage, and have been eligible for medicare for less than 30 months.
receive workers’ compensation
Your workers’ compensation will pay first if you get hurt or sick on the job. Medicare will pay second. For any medical services received that are not related to the workers’ compensation claim, Medicare will pay first.
federal black lung program
if you are covered by the federal black lung program, the program will pay first and medicare will pay second.
no coordination of benefits
When there is no coordination of benefits, policies will not work together or complement each other. some examples include when you have a medicare benefits plan, a marketplace plan, or veterans benefits. Medicare does not coordinate with these health care programs.
By having both Veterans and Medicare benefits, you gain access to all civilian and non-civilian doctors and hospitals.
frequently asked questions
