Joel Mekler | Medicare Moments: Medicare: primary or secondary? | Lifestyles

How does Medicare coordinate with other group insurance coverage?

When is Medicare primary, and when is it secondary? Here are some examples of additional coverage that people may have: Medicaid, Medigap, a current or former employer or union, COBRA, the Federal Employees Health Benefits Program, TRICARE, Veterans Affairs, the Indian Health Service, the Federal Black Lung Benefits Program, workers’ compensation, and no-fault insurance or liability insurance.

So, the question arises: What if you have two types of coverage – Medicare plus another? What if you have three types, four, or even more? How do your medical bills get paid? How does it all work together? Medicare expects you to know.

Here’s how it works: Each type of insurance you have, Medicare included, is known as a payer. If you have more than one payer, Medicare’s coordination of benefits rules determines which one pays first (or second or third). So, when you go to a doctor or other provider, the bill is sent to the first payer – the primary payer – who pays what it owes. If that amount doesn’t fully meet the bill, the provider sends the remainder to the next payer (the secondary payer) and may even a third.

How smoothly the system works depends on Medicare receiving vast amounts of information from employers, insurance companies, doctors, and other health care providers. It should also come from you when you first become eligible for Medicare and later if your coverage changes.

Medicare doesn’t automatically know what other health coverage (if any) you have. So about three months before you become eligible for Medicare, you receive a letter telling you how to complete the Medicare Initial Enrollment Questionnaire through the mail. Completing this questionnaire is very much in your interest. Your answers help Medicare make sure that payments for medical services you use are made promptly and accurately.

Over time, of course, your coverage may change. If any changes may affect how Medicare fits in with other insurance – for example, if you stop work or otherwise lose coverage from a current employer – you should contact Medicare’s Benefits Coordination & Recovery Center (BCRC) to ensure these new circumstances are recorded in your file. The BCRC is also available for you to ask questions about your coverage and how it fits in with Medicare. Call toll-free 855-798-2627 (TTY 855-797-2627).

WHEN IS MEDICARE PRIMARY COVERAGE?

Medicare will always be your primary insurance if you don’t have any other insurance. There are several situations when Medicare is primary. Learning about them ahead of time will help you avoid costly enrollment deadlines.

You are 65 or older, and your employer is a small business. Medicare is primary when your employer has less than 20 employees. Medicare will pay first, and then your group insurance will pay second. If this is your situation, enrolling in both parts of Original Medicare is essential when you are first eligible for coverage at age 65. This rule applies…