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

Date:


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.

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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 to spouses on the same coverage as well.

You have retiree coverage or COBRA. Sometimes a former employer provides group health insurance coverage for you after you are no longer working. This is called retiree coverage. Medicare is primary, and your providers must submit claims to Medicare first. Your retiree coverage through your employer will pay secondary. Often your retiree coverage will provide prescription drug benefits, so you may not need to purchase Part D. Ask your former employer for a Summary of Benefits for your group plan. This document will usually clearly explain the benefits you can expect after Medicare pays first. Similarly, Medicare will pay primary to COBRA, so enrolling in Parts A and B is essential. You must enroll in Part B within the first eight months of COBRA. Otherwise, you will face a late enrollment penalty. You may also be subject to a waiting period before enrolling in Part B during the next General Election Period.

You are on SSDI (Social Security Disability Insurance) under age 65 at a medium-sized employer. Some people qualify for Medicare early due to a disability. Medicare is primary if you have group coverage through an employer with less than 100 employees. When you reach your 24th month of SSDI benefits, Medicare will automatically enroll you in Parts A and B. Be sure to notify your employer of your Medicare coverage.

You have end-stage renal disease. People with End-Stage Renal Disease (ESRD) will automatically transition to Medicare as primary after the 30th month. Your employer insurance from any current job is primary for the first 30 months. This applies to current employer coverage as well as retiree insurance and COBRA. Medicare will pay secondary in all of these situations if you have ESRD. Please note that Medicare obtained due to ESRD could end after you’ve received a successful kidney transplant. You would then re-enroll when you turn 65. Typically, Medicare due to ESRD will end 36 months after your kidney transplant unless you also qualify for Medicare due to age or other disability.

You have Tricare-for-Life. Tricare-for-Life (TFL) is for military retirees and their spouses who are also eligible for Medicare. In this scenario, Medicare is the primary insurance for any care you receive from non-military providers, so you need to enroll in Part A and B. Since TFL provides drug coverage, you don’t need to enroll in Part D. The drug coverage under Tricare is good, and additional Part D coverage is generally unnecessary.

You have Medicaid. Medicaid is assistance with healthcare costs for people with low incomes. Medicaid never pays first. It will only pay after Medicare and employer group health coverage is paid first. Not all Medicare providers accept Medicaid, though. You must ask providers if they participate in Medicaid before seeking care. Otherwise, you may be responsible for the portions that Medicaid can’t cover. People who qualify for Medicaid can get help paying for their Medicare Part B and D premiums. If your income is low and you think you might be eligible, contact your state Medicaid office for an application.

WHEN IS MEDICARE SECONDARY?

There are a few scenarios where Medicare becomes secondary coverage. Let’s look at the most popular ones:

You still have group coverage through larger employer. If you or your spouse receives group insurance through their employment at a company that employs more than 20 people, Medicare will serve as secondary coverage to that insurance plan. Some Medicare beneficiaries will choose to delay their Part B enrollment if their group coverage is cheaper.

You’re under 65 and disabled with large employer group coverage. If you’re under 65, eligible for Medicare due to a disability, and have group employer coverage through an employer with more than 100 employees, Medicare will be your secondary payer.

You are on active military duty. If you’re on active duty, TRICARE first pays for Medicare-approved services at civilian facilities. And Medicare doesn’t cover treatment provided by a military hospital or federal health care provider: that will all go through TRICARE or your VA benefits.

You have filed a Workers Compensation claim. If you have Medicare and get injured on the job, your worker’s compensation will pay first for any healthcare services you seek due to your work-related injury.

Figuring all this out is enough to give anyone a headache. This is tricky, and getting it wrong can have costly enrollment consequences.

Listed below are two excellent resources from the Medicare Rights Center and the Centers for Medicare & Medicaid Services.

(Joel Mekler is a certified senior adviser. Send him your Medicare questions at mekbab2000@verizon.net.)



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