If you have Medicare and other health insurance (like from a group health plan, retiree coverage, or Medicaid), 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 sends the rest to the " secondary payer" (supplemental payer)to pay. In some rare cases, there may also be a third payer.
What it means to pay primary/secondary
- The insurance that pays first (primary payer) pays up to the limits of its coverage.
- The one that pays second (secondary payer) only pays if there are costs the primary insurer didn't cover.
- The secondary payer (which may be Medicare) may not pay all the remaining costs.
- If your group health plan or retiree coverageis the secondary payer, you'll likely need to enroll in MedicarePart Bbefore they'll pay.
If the insurance company doesn't pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should've made.
How Medicare coordinates with other coverage
If you havequestions about who pays first, or if your coverage changes, call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627). Tell your doctor and other health care provider about any changes in your insurance or coverage when you get care.
I have Medicare and:
- I'm 65 or older and have group health plan coverage based on my or my spouse's current employment status.
If the employer has 20 or more employees, then the group health plan pays first, and Medicare pays second.
If the group health plan didn't pay all of your bill, the doctor or health care provider should send the bill to Medicare for secondary payment. You may have to payany costs Medicare or the group health plan doesn't cover.
- Employers with 20 or more employees must offer current employees 65 and older the same health benefits under the same conditions that they offer employees under 65. If the employer offers coverage to spouses, it must offer the same coverage to spouses 65 and older that they offer to spouses under 65.
- If the employer has less than 20employees and isn't part of a multi-employer or multiple employer group health plan, then Medicare pays first, and the group health plan payssecond.
- If the employer has less than 20 employees, the group health plan pays first, and Medicare pays second if both of these conditions apply:
- The employer is part of a multi-employer or multiple employer group health plan
- At least one of the other employers has 20 or more employees
Check with your plan first and ask if it will pay first or second.
- I'm in a Health Maintenance Organization (HMO) Plan or an employer Preferred Provider Organization (PPO) Plan that pays first, and I get services outside the group health plan's network.
It's possible that neither the plan nor Medicare will pay if you get care outside your plan's network. Before you go outside the network, call your planto find out if it will cover the service.
- I dropped employer-offered coverage.
If you’re 65 or older, Medicare pays first unless both of these apply:
- You have coverage through an employed spouse.
- Your spouse's employer has at least 20 employees.
Call your employer's benefits administrator for more information.
- I'm 65 or older, retired, and have group health plan coverage from my spouse's current employer.
Your spouse’s plan pays first, and Medicare pays second when all of these conditions apply:
- You’re retired, but your spouse is still working.
- You’re covered by your spouse’s group health plan coverage.
- Your spouse’s employer has 20 or more employees, or has less than 20 employees, but is part of a multi-employer plan or multiple employer plan.
If the group health plan doesn't pay all of a bill, the doctor or health care provider should send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn’t cover.
- I'm under 65, disabled, retired and I have group health coverage from my former employer.
If you're not currently employed, Medicare pays first, and yourgroup health plan coveragepays second.
- I'm under 65, disabled, retired and I have group health coverage from my family member's current employer.
- If the employer has 100 or more employees, then your family member's group health plan pays first, and Medicare pays second.
- If the employer has less than 100 employees, but is part of a multi-employer or multiple employer group health plan, your family member's group health plan pays first and Medicare pays second.
- If the employer has less than 100 employees, and isn’t part of a multi-employer or multiple employer group health plan, then Medicare pays first, and your family member's group health plan pays second.
- I have Medicare due to End-Stage Renal Disease (ESRD), and group health plan coverage (including retiree coverage).
When you’re eligible for or entitled to Medicare becauseyou have ESRD, your group health plan pays first, and Medicare pays second during a coordination period that lasts up to 30 months. You can have group health plan coverage or retiree coveragebased on your employment or through a family member.
After the coordination period ends, Medicare pays first and your group health plan (or retiree coverage) pays second.
- I have group health plan coverage. I first got Medicare because I turned 65 or because of a disability (other than End-Stage Renal Disease (ESRD)), and now I have ESRD.
Whichever coverage paid first when you originally got Medicare will continue to pay first. You can have group health plan coverage or retiree coveragebased on your employment or through a family member.
- I have Medicare due to End-Stage Renal Disease (ESRD), and have COBRA coverage.
When you’re eligible for or entitled to Medicare due to ESRD, COBRA pays first, and Medicare pays second during a coordination period that lasts up to 30 months after you're first eligible for Medicare. After the coordination period ends, Medicare pays first.
- I get health care services from Indian Health Service (IHS) or anIHS provider.
- If you have non-tribal group health plan coverage through an employer who has 20 or more employees, the non-tribal group health plan pays first, and Medicare pays second.
- If you have non-tribal group health plan coverage through an employer who has less than 20 employees, Medicare pays first, and the non-tribal group health plan pays second.
- If you have a group health plan through tribal self-insurance, Medicare pays first and the group health plan pays second.
- I've been in an accident where no-fault or liability insurance is involved.
No-fault insurance or liability insurancepays first and Medicare pays second.
If the no-fault or liability insurance denies your medical bill or is found not liable for payment, Medicare pays first, but only pays for Medicare-covered services. You're still responsible for your share of the bill (like coinsurance, a copayment or a deductible) and for the cost of services Medicare doesn't cover.
If your provider knows you have a no-fault or liability insurance claim, they must try to get paid by the insurance company before billing Medicare. If the insurance company doesn't pay the claim promptly (usually within 120 days), your provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then will recover any payments the primary payer should have made later.
If Medicare makes a conditional payment, and you get a settlement from an insurance company later, you're responsible for making sure Medicare gets repaid.
If you file a no-fault insurance or liability insurance claim and Medicare makes a conditional payment, you or your representative should report the claim and payment by calling the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627).
The Benefits Coordination & Recovery Center:
- Gathers information about conditional payments Medicare makes.
- Calculates the final amount owed (if any) on your recovery case.
- Send you a letterasking forrepayment.
If you get a settlement, judgment, award or other payment, you or your representative should contact the Benefits Coordination & Recovery Center.
- I'm covered under workers' compensation because of a job-related illness.
Workers’ compensation pays first for services or items related to the workers’ compensation claim. Medicare may make a conditional payment if the workers’ compensation insurance company denies payment for your medical bills for 120 days or more, pending a review of your claim.
Find out more abouthow settling your claim affects Medicare payments.
- I'm a Veteran and have Veterans' benefits.
If you have (or can get) both Medicare and Veterans’ benefits, you can get treatment under either program. Generally, Medicare and the U.S. Department of Veterans Affairs (VA) can’t pay for the same service or items. Medicare pays for Medicare-covered services or items. The VA pays for VA-authorized services or items. Each timeyou get health care or see a doctor, you must choose which benefits to use.
For the VA to pay for services, you must go to a VA facility or have the VA authorize services in a non-VA facility.
If the VA authorizes services in a non-VA hospital, but didn’t authorize all of theservices you get during your hospital stay, then Medicare may pay for any Medicare-covered services the VA didn’t authorize.
- I'm covered under TRICARE.
If you're on active duty and enrolled in Medicare, TRICARE pays first for Medicare-covered services or items, and Medicare pays second. If you're not on active duty,Medicare pays first for Medicare-covered services, and TRICAREmaypay second.
If you get items or services from a military hospital or any other federal health care provider, TRICARE pays first.
Get more information onTRICARE.
- I have coverage under the Federal Black Lung Program.
For any health care related to black lung disease, the Federal Black Lung Program pays first as long as the program covers the service.Medicare won't pay for doctor or hospital services covered under the Federal Black Lung Program.
Your doctor or other health care provider should send all bills for the diagnosis or treatment of black lung disease to:
Federal Black Lung Program
PO Box 8302
London, KY 40742-8302For all health care not related to black lung disease, Medicare pays first, and your doctor or health care provider should send your bills directly to Medicare.
If the Federal Black Lung Program won't pay your bill, ask your doctor or other health care provider to send Medicare the bill. Also ask them to include a copy of the letter from the Federal Black Lung Benefits Program explaining why they won’t pay your bill.
If you have questions about the Federal Black Lung Program, call 1-800-638-7072.
- I have COBRA continuation coverage.
If you have Medicare because you’re 65 or over or because you're under 65 andhave a disability (not End-Stage Renal Disease (ESRD)), Medicare pays first.
If you have Medicare due to ESRD, COBRA pays first and Medicare pays second during a coordination period that lasts up to 30 months after you’re first eligible for Medicare. After the coordination period ends, Medicare pays first.
Find out more in7 facts about COBRA.
- I have more than one other type of insurance or coverage.
If you have Medicare and more than one other type of insurance, check your policy or coverage information for rules about who pays first. You can also call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627).
Tell your doctor and other health care providers if you have coverage in addition to Medicare. This will help them send your bills to the correct payer and avoid delays.
What's a conditional payment?
A conditional payment is a payment Medicare makes for services another payer may be responsible for. Medicare makes this conditional payment so you won't have to use your own money to pay the bill. The payment is "conditional" because it must be repaid to Medicare if you get a settlement, judgment, award, or other payment later.
You’re responsible for making sure Medicare gets repaid from the settlement, judgment, award, or other payment.
How Medicare recovers conditional payments
If Medicare makes a conditional payment, and you or your representative haven't reported your settlement, judgment, award or other payment to Medicare, call the Benefits Coordination & Recovery Centerat 1-855-798-2627. (TTY:1-855-797-2627).
The Benefits Coordination & Recovery Center:
- Gathers information about conditional payments Medicare makes.
- Calculates the final amount owed (if any) on your recovery case.
- Sends you a letter asking for repayment.
