Department of Human Services

Making Medicare Make Sense June 2012

Answers To Some Of The Most Commonly Asked Questions

June 1, 2012 | 3 min reading time

Q:  Who Pays First If I Have Medicare and Other Health Coverage?

A:  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 your provider sends the rest to the "secondary payer" to pay. In some 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 below. However, this chart doesn't cover every situation. Be sure to tell your doctor and other health care provider's insurance specialist/billing staff if you have 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 whole bill up to the limits of the payer's coverage. It doesn't always mean the primary payer pays first in time.

If you have questions about who pays first or if your coverage changes, call the Medicare Coordination of Benefits Contractor (COBC) at 1-800-999-1118. TTY users should call 1-800-318-8782 For example, if you need to find out about Medicare's coverage of End Stage Renal Disease and how it works with other insurance the COBC will answer your questions.  Also, to better serve you please have the following information ready when you call: your Medicare number (located on your red, white, and blue Medicare card) and one additional piece of information, such as your Social Security Number (SSN), address, Medicare effective date(s), or whether you have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) coverage.

Below is a summary chart of who likely pays first. If you would like a copy of the Medicare booklet referenced in the chart, titled, "Medicare and Other Health Benefits: Your Guide to Who Pays First," call 1-800-633-4227, (which is 1-800-Medicare), and ask for CMSProduct Number 02179, and tell them the title of the booklet.

Please note: In some cases, if you are entitled to, but don't have, the first payer coverage, the second payer won't cover you.  This can be vital information to know in some employer retiree plans and COBRA cases.  For instance, if you are 65 and older, and retired, and you do not enroll in Medicare, it is possible that your retiree coverage won't cover you.  Check with your retiree plan to be sure.

If You: Situation Pays First
Pays Second
See Page(s)

(in publication #02179)

Are covered by Medicare and Medicaid
Entitled to Medicaid
Medicare Medicaid, but only after other coverage (such as employer group health plans) has paid
8

 

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

__________

Have and employer group health plan after you retire and are 65 or older

Entitled to Medicare

________

The employer has 20 or more employees

____________

The employer has less than 20 employees*

Group health plan

 

_________

 

Medicare

Medicare

 

_______________

Retiree coverage

8

___________

10-11

Are disabled and covered by a large group health plan from your work, or from a family member who is working

 

Entitled to Medicare
____________

The employer has 100 or more employees

____________

The employer has less than 100 employees

 

Large group health plan

____________

Medicare

Medicare

_____________

Group health plan

12

_________

12

Are 65 or over OR disabled and covered by Medicare and COBRA coverage
Entitled to Medicare
Medicare COBRA 22-23
Have been in an accident where no-fault or liability insurance is involved
Entitled to Medicare
No-fault or liability insurance for services related to accident claim
Medicare 13-15
Are covered under worker's compensation because of a job-related illness or injury
Entitled to Medicare
Worker's compensation for services related to worker's compensation claim
Usually doesn't apply.  However, Medicare may make a conditional payment.
15-19
Are a veteran and have Veterans' benefits
Entitled to Medicare and Veterans' benefits
Medicare pays for Medicare-covered services.

Veterans' Affairs pays for VA-authorized services.

Note: Generally, Medicare and VA can't pay for the same service

Usually doesn't apply
19-20
Are covered under TRICARE
Entitled to Medicare and TRICARE
Medicare pays for Medicare-covered services.

TRICARE pays for services from a military hospital or any other federal provider.

TRICARE may pay second.
20-21
*If your employer participates in a plan that is sponsored by two or more employers, the rules are slightly different.


Department of Human Services

City of St. Louis

 

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