If you’re 65 or older and still working, chances are you have both Medicare and healthcare insurance provided through your employer. Which brings up an important question when a bill is due for healthcare services provided:
Who pays first?
The same question applies if you’re retired and have both Medicare and coverage through your former employer, or you’re covered by both Medicare and your spouse’s employer healthcare plan.
To answer this question, you must first determine which insurance plan is the primary payer. And that’s where coordination of benefits (COB) rules come into play. While there are numerous possible scenarios, here are a few of the most common.
If you are 65 or older, have Medicare, and…
- You are covered by a group health plan through your employer:
– If your employer has 20 or more employees, the group health plan pays first and Medicare pays second.
– If your employer has fewer than 20 employees, Medicare pays first and the group health plan pays second.
- You are covered by a group health plan through your spouse’s employer:
– If your spouse’s employer has 20 or more employees, the group health plan pays first and Medicare pays second.
– If your spouse’s employer has fewer than 20 employees, Medicare pays first and the group health plan pays second.
- You are retired and are covered by a group health plan through your former employer (or the former employer of your spouse):
– Medicare pays first and the group health plan pays second.
A detailed list of COB scenarios is available on the official Medicare site.
To avoid delays (and confusion), be sure to inform your doctor and other providers if you have healthcare coverage in addition to Medicare. This way, they know to where to send bills.
How much do they pay?
The answer to this question is a little more straightforward.
– The primary payer pays first, up to the coverage limit.
– If a balance remains, the secondary payer may cover some or all of that amount.
Keep in mind, the primary payer may not actually be the first to pay. For example, if your insurance company is the primary payer and does not pay a claim promptly, the provider may bill Medicare (the secondary payer in this scenario). Medicare, in turn, may pay the bill and recover the amount the primary payer should have paid.
What else should you know?
Medicare may make payments for services for which another payer is responsible. This is known as a conditional payment. Medicare makes conditional payments so you don’t have to use your own money to pay a bill. However, you must make sure Medicare is repaid if you later receive a settlement, judgment, award, or other form of payment.
If you have questions about coordination of benefits or conditional payments, contact the Benefits Coordination & Recover Center (BCRC) at 1-855-798-2627 (TTY: 1-855-797-2627).