Wondering ! How Medicare Works and who pays first ?!

Some people with Medicare have other health coverage that must pay before Medicare pays its share of the bill. This guide tells how Medicare works with other kinds of coverage and who should pay your bills first.Tell your doctor, hospital, and all other health care providers about your other health coverage to make sure your bills are sent to the right payer to avoid delays.

Coordination of benefits

If you have Medicare and other health coverage, each type of coverage is called a “payer.” When there’s more than one payer, “coordination of benefits” rules decide who pays first. The “primary payer” pays what it owes on your bills first,and then you or your health care provider sends the rest to the “secondary payer” to pay. In some rare cases, there may also be a “third payer.”Whether Medicare pays first depends on a number of things, including the situations listed in the chart on the next 3 pages. However, this chart doesn’t cover every situation. Be sure to tell your doctor and other providers if you have health coverage in addition to Medicare. This will help them send your bills to the correct payer to avoid delays. Note: Paying “first” means paying the bill up to the limits of the payer’s coverage. It doesn’t mean the primary payer is always the first one in time to pay its share of the costs.

How Medicare works with other coverage

Use the chart below to find your type(s) of coverage and situation to see which payer pays first.

1. If you : Are covered by Medicare and Medicaid

Situation : Entitled to Medicare and Medicaid

Pays first : Medicare

Pays second : Medicaid

2. If you : Are 65 or older and covered by a group health plan because you or your spouse is still working

Situation : A. Entitled to Medicare //// B. The employer has 20 or more employees /// C. The employer has less than 20 employees

Pays first : A Group health plan /// B. Medicare

Pays second : A. Medicare /// B. Group health plan

3. If you : Have an employer group health plan through your former employer after you retire and are 65 or older

Situation : Entitled to Medicare

Pays first : Medicare

Pays second : Medicare

4. If you : Are disabled and covered by a large group health plan from your work, or from a family member (like spouse, domestic partner, son, daughter, or grandchild) who’s working

Situation : A. Entitled to Medicare /// B. The employer has 100 or more employees /// C. The employer has less than 100 employees

Pays first : A. Large group health plan /// B. Medicare

Pays second : A. Medicare /// B. Group health plan

5. If you : *Have End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) and group health plan coverage (including a retirement plan)

Situation : A. First 30 months of eligibility or entitlement to Medicare /// B. After 30 months of eligibility or entitlement to Medicare

Pays first : A. Group health plan /// B. Medicare

Pays second : A. Medicare /// B. Group health plan

6. If you : Have ESRD and COBRA coverage

Situation : A. First 30 months of eligibility or entitlement to Medicare based on having ESRD /// B. After 30 months

Pays first : A. COBRA /// B. Medicare

Pays second : A. Medicare /// B. COBRA

7. If you : Are 65 or over OR disabled (other than by ESRD) and covered by Medicare and COBRA coverage

Situation : Entitled to Medicare

Pays first : Medicare

Pays second :COBRA

8. If you : Have been in an accident where no-fault or liability insurance is involved

Situation : Entitled to Medicare

Pays first : No-fault or liability insurance for services or items related to accident claim

Pays second : Medicare

9. If you : Are covered under workers’ compensation because of a job‑related illness or injury

Situation : Entitled to Medicare

Pays first : Workers’ compensation for services or items related to workers’ compensation claim

Pays second : Usually doesn’t apply. However, Medicare may make a conditional payment (a payment that must be repaid to Medicare when a settlement, judgment, ward, or other payment is made.)

10. If you : Are a Veteran and have Veterans’ benefits

Situation : Entitled to Medicare and Veterans’ benefits

Pays first : Medicare pays for Medicare-covered services or items.

Veterans’ Affairs pays for VA-authorized services or items.

Note: Generally, Medicare and VA can’t pay for the same service or items.

Pays second : Usually doesn’t apply

11. If you : Are covered under TRICARE

Situation : Entitled to Medicare and TRICARE

Pays first : Medicare pays for Medicare-covered services or items. TRICARE pays for services or items from a military hospital or any other federal provider.

Pays second : TRICARE may pay second.

12. If you : Have black lung disease and are covered under the Federal Black Lung Benefits Program

Situation : Entitled to Medicare and the Federal Black Lung Benefits Program

Pays first : The Federal Black Lung Benefits Program for services related to black lung.

Pays second : Medicare

How Medicare works with other coverage (continued)

Example: John Doe recently turned 65 and is eligible to enroll in Medicare.He works for a large company with more than 20 people and has coverage through his employer’s group health plan. The insurer sends John a questionnaire asking whether John is still currently working. If John replies that he’s still working, the insurer will report John’s group health plan insurance information to Medicare so that Medicare knows to pay John’s claims second.

How Medicare works with other coverage (continued)

Generally, no. It’s against the law for someone who knows that you have Medicare

to sell or issue you a Marketplace policy. This is true even if you have only

Medicare Part A or only Medicare Part B. Therefore, if you already have Medicare, you shouldn’t need to coordinate benefits between Medicare and a Marketplace plan. On the other hand, if you don’t yet have Medicare but have coverage through the Marketplace, you can choose to keep your Marketplace plan after your Medicare coverage starts. But, if you’ve been getting premium tax credits or other savings on a plan you bough through the Marketplace, these savings will end once your Part A coverage starts, so you’d have to pay full price for the Marketplace plan. If you age into Medicare and decide to keep your Marketplace plan, then Medicare pays first. Where can I get more information about who pays first? Call your health insurance plan’s benefits administrator. You can also call the

Benefits Coordination & Recovery Center (BCRC) toll-free at 1-855‑798‑2627.

TTY users should call 1-855-797-2627..

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