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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 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
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
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
Pays second :COBRA
8. If you : Have been in an accident where no-fault or liability insurance is involved
Pays first : No-fault or liability insurance for services or items related to accident claim
9. If you : Are covered under workers’ compensation because of a job‑related illness or injury
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.
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..
If you More Questions about Medicare Claims Than please contact us for Free Advice
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