FAQ

How Medicare works with other insurance | Medicare

if you have

and other health insurance (such as a group health plan, retiree coverage, or Medicaid), each type of coverage is called a “payer.” When there is more than one payer, “coordination of benefits” rules decide who pays first. the “primary payer” first pays what is owed on your bills, and then sends the rest to the “secondary payer” (supplementary payer) for payment. in some rare cases, there may also be a third party payer.

Reading: Which insurance is primary with medicare

what does it mean to pay primary/secondary

  • 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 that the primary insurer did not cover.
  • the secondary payer (which may be medicare) may not pay all of the remaining costs.
  • if your group health plan or retiree coverage is the secondary payer, you may need to sign up for medicare part b before they pay.
  • if the insurance company doesn’t pay

    promptly (usually within 120 days), your doctor or other provider can bill medicare. Medicare can make a conditional payment to pay the bill and then recover the payments that should have been made by the primary payer.

    how medicare coordinates with other coverage

    If you have questions about who pays first or if your coverage changes, call Coordination of Benefits & recovery center at 1-855-798-2627 (tty: 1-855-797-2627). tell your doctor and others

    About any changes to your insurance or coverage when you receive care.

    I have medicare and:

    • If the employer has 20 or more employees, then the group health plan pays first and Medicare pays second.

      if the

      You didn’t pay your entire bill, the doctor, or

      You must bill Medicare for secondary payment. You may have to pay any costs that Medicare or the group health plan doesn’t cover.

      Employers with 20 or more employees must offer current employees age 65 and older the same health benefits on the same terms as they offer to employees under age 65. if the employer offers coverage to spouses, she must offer the same coverage to spouses age 65 and older. offered to spouses under 65 years of age.

    • If the employer has fewer than 20 employees and is not part of a multi-employer or multi-employer group health plan, Medicare pays first and the group health plan pays second.
    • If the employer has fewer than 20 employees, the group health plan pays first and Medicare pays second if both of these conditions apply:
    • employer is part of a multi-employer or multi-employer group health plan
    • at least one other employer has 20 or more employees

      check with your plan first and ask if you’ll pay first or second.

      Neither the plan nor Medicare may pay if you get care outside of your plan’s network. Before you go out of network, call your plan to find out if it will cover the service.

      If you’re 65 or older, Medicare pays first unless both apply:

      • You have coverage through an employed spouse.
      • Your spouse’s employer has at least 20 employees.
      • Call your employer’s benefits administrator for more information.

        your spouse’s plan pays first and Medicare pays second when all of these conditions apply:

        • You are retired, but your spouse is still working.
        • is covered by your spouse’s group health plan coverage.
        • Your spouse’s employer has 20 or more employees, or has fewer than 20 employees, but is part of a multiemployer plan or a multiemployer plan.
        • If the group health plan doesn’t pay the entire bill, the doctor or health care provider must submit the bill to Medicare for secondary payment. You may have to pay any costs that Medicare or the group health plan doesn’t cover.

          If you’re not currently employed, Medicare pays first and your group health plan coverage pays second.

          • If the employer has 100 or more employees, then your family member’s group health plan pays first and Medicare pays second.
          • If the employer has fewer than 100 employees, but is part of a multi-employer or multi-employer group health plan, your family member’s group health plan pays first and Medicare pays second.
          • If the employer has fewer than 100 employees and is not part of a multi-employer or multi-employer group health plan, Medicare pays first and your family member’s group health plan pays second.
          • See also: How Much Does a Teeth Cleaning Cost With and Without Insurance?

            When you are eligible or entitled to Medicare because you have ESRD, your group health plan pays first and Medicare pays second for a coordination period that lasts up to 30 months. You may have group health plan coverage or retiree coverage based on your job or through a family member.

            After the coordination period ends, Medicare pays first and your group health plan (or retiree coverage) pays second.

            whatever coverage you paid for first when you originally got medicare, will continue to pay first. You may have group health plan coverage or retiree coverage based on your job or through a family member.

            when you are eligible or entitled to medicare due to an esrd, collect pays first and medicare pays second during a coordination period that lasts up to 30 months after you first become eligible for medicare. After the coordination period ends, Medicare pays first.

            • If you have coverage from a non-tribal group health plan through an employer that has 20 or more employees, the non-tribal group health plan pays first and Medicare pays second.
            • If you have coverage from a non-tribal group health plan through an employer with fewer than 20 employees, Medicare pays first and the non-tribal group health plan pays second.
            • If you have a group health plan through tribal self-insurance, Medicare pays first and the group health plan pays second.
            • no-fault or liability insurance pays first and medicare pays second.

              If no-fault or liability insurance denies your medical bill or is found not responsible for payment, Medicare pays first, but only pays for Medicare-covered services. you remain responsible for your portion of the bill (such as

              , a

              or a

              ) and for the cost of services that Medicare does not cover.

              If your provider knows you have a no-fault or liability insurance claim, you should try to get the insurance company to pay you before billing Medicare. If the insurance company doesn’t pay the claim right away (usually within 120 days), your provider can bill Medicare. Medicare can make a conditional payment to pay the bill, and then will recover any payment that the primary payer should have made later.

              if medicare does a

              , and then you get a settlement from an insurance company, you are responsible for making sure that medicare is reimbursed.

              If you file a no-fault or liability insurance claim and Medicare makes a conditional payment, you or your representative must report the claim and payment by calling Coordination of Benefits & recovery center at 1-855-798-2627 (tty: 1-855-797-2627).

              coordination of benefits & recovery center:

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