How Medicare works with other insurance

If you have 

Medicare

 and other health insurance or coverage, each type of coverage is called a "payer." When there's more than one payer, "coordination of benefits" rules decide which one 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 uncovered costs.
  • If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will 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 your questions about who pays first, or if your coverage changes, call the Benefits Coordination & Recovery Center (BCRC) 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 own current employment status or the current employment of my spouse.

If your or your spouse's 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. Medicare will pay based on what the group health plan paid, what the group health plan allowed, and what the doctor or health care provider charged on the claim. You'll have to pay any 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, they must offer the same coverage to spouses 65 and older that they offer to spouses under 65.

If your or your spouse's employer has less than 20 employees and isn't part of a multi-employer or multiple employer group health plan, then Medicare pays first, and the group health plan pays second.

Medicare pays first. Medicare may pay second if both of these apply:

  • Your employer, which has less than 20 employees, joins with other employers or employee organizations (like unions) to sponsor a group health plan (called a multi-employer plan), and
  • At least one or more of the other employers has 20 or more employees.

However, your plan may ask for an “exception” and request not to be part of a multi-employer group health plan. Check with your plan first and ask whether it will pay first or second for your claims.

 

I'm in a Health Maintenance Organization (HMO) Plan or an employer Preferred Provider Organization (PPO) Plan that pays first through my employer and I get services outside the employer plan's network.

It's possible that neither the plan nor Medicare will pay if you get care outside your employer plan's network. Before you go outside the network, call your employer group health plan to find out if it will cover the service.

I have dropped employer-offered coverage.

If you’re 65 or older, Medicare pays first unless these apply:

  • You have coverage through an employed spouse.
  • Your spouse’s employer has at least 20 employees.

If you don't take employer coverage when it's first offered to you, you might not get another chance to sign up. If you take the coverage but drop it later, you may not be able to get it back. Also, you might be denied coverage if your employer or your spouse's employer generally offers retiree coverage, but you weren't enrolled in the plan while you or your spouse were still working.

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 the following apply:

  • You’re retired, but your spouse is still working, and
  • You’re covered by your spouse’s group health plan coverage, and
  • Your spouse’s employer must have 20 or more employees, unless the employer has less than 20 employees, but is part of a multi-employer plan or multiple employer plan.

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. Medicare may pay based on what the group health plan paid, what the group health plan allowed, and what the doctor or health care provider charged on the claim. 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.

Medicare pays first and your group health plan (retiree) coverage pays second if you get group health plan coverage through your own former employer and you're not currently employed.

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 the large 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 the group health plan pays second. If the employer is part of a multi-employer or multiple employer group health plan, the group health plan pays first and Medicare pays second.
I have Medicare due to End-Stage Renal Disease (ESRD), and group health plan coverage (including a retirement plan).

When you’re eligible for or entitled to Medicare because you have End-Stage Renal Disease (ESRD), during a coordination period of up to 30 months, the group health plan pays first and Medicare pays second.

After the coordination period, Medicare pays first and the group health plan pays second. If you originally got Medicare due to your age or a disability other than ESRD, and your group health plan was your primary payer, then it still pays first when you become eligible because of ESRD.

I have group health plan coverage, I first got Medicare due to turning 65 or because of a disability (other than End-Stage Renal Disease (ESRD)), and now I have ESRD.

Whichever coverage paid first due to your age or non-End-Stage Renal Disease (non-ESRD) disability still pays first when you become eligible for Medicare because of ESRD:

  • If you originally got Medicare due to your age or a disability (other than ESRD) and Medicare paid first, then Medicare continues to pay first even when you become eligible for Medicare because of ESRD.
  • If you originally got Medicare due to your age or a disability (other than ESRD) and your group health plan paid first, then it still continues to pay first when you become eligible because of ESRD.
I have Medicare due to End-Stage Renal Disease (ESRD), and COBRA coverage.

When you’re eligible for or entitled to Medicare due to End-Stage Renal Disease (ESRD), during a coordination period of up to 30 months, COBRA pays first. Medicare pays second, to the extent COBRA coverage overlaps the first 30 months of Medicare eligibility or entitlement based on ESRD.

I get health care services from the Indian Health Service (IHS) or an IHS provider.
  • If you have group health plan coverage through an employer who has 20 or more employees, the group health plan pays first, and Medicare pays second.
  • If you have group health plan coverage through an employer who has less than 20 employees, Medicare pays first, and the 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 insurance pays first and Medicare pays second.

No-fault insurance pays for health care services resulting from injury to you or damage to your property in an accident, regardless of who is at fault for causing the accident. Types of no-fault insurance include:

  • Automobile insurance
  • Homeowners' insurance
  • Commercial insurance plans

Liability insurance protects against claims for negligence—inappropriate action or inaction that results in injury to someone or damage to property. Types of liability insurance include:

  • Homeowners' liability insurance
  • Automobile liability insurance
  • Product liability insurance
  • Malpractice liability insurance
  • Uninsured motorist liability insurance
  • Underinsured motorist liability insurance

If the no-fault or liability insurance denies the medical bill or is found not liable for payment, Medicare pays the same as it would if it were the only payer. But, Medicare only pays for Medicare-covered services; you're responsible for your share of the bill—for example, 

Coinsurance

, a 

Copayment

 or a 

Deductible [glossary]

—and for services Medicare doesn't cover.

If doctors or other providers are told you have a no-fault or liability insurance claim, they must try to get payments from the insurance company before billing Medicare. But, this may take a long time. 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 have made.

If Medicare makes a 

conditional payment

, and you get a settlement from an insurance company later, the conditional payment from your settlement needs to go to Medicare. You're responsible for making sure Medicare gets repaid for the conditional payment.

If you have an insurance claim for your medical expenses, you or your attorney should notify Medicare as soon as possible. If you have questions about a no-fault or liability insurance claim, call the insurance company.

If you file a no-fault insurance or liability insurance claim, you or your representative should call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 (TTY: 1-855-797-2627). 

The BCRC will gather information about any conditional payments Medicare made related to your no-fault insurance or liability insurance claim. If you get a settlement, judgment, award or other payment, you or your representative should contact the BCRC. The BCRC will determine the final repayment amount (if any) on your recovery case and send you a letter asking for repayment.

I'm covered under workers' compensation because of a job related illness or injury.

Workers’ compensation pays first for services or items related to the workers’ compensation claim. Medicare may make a conditional payment (a payment that must be repaid to Medicare when a settlement, judgment, award, or other payment is made).

Find out more about how 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. 

If you have or can get both Medicare and Veterans’ benefits, you can get treatment under either program. Generally, Medicare and VA can’t pay for the same service or items. Medicare pays for Medicare-covered services or items. Veterans’ Affairs pays for VA-authorized services or items.

When you get health care, you must choose which benefits to use each time you see a doctor or get health care.

Note 

To get the U.S. Department of Veterans Affairs (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 the services you get during your hospital stay, then Medicare may pay for the Medicare-covered services the VA didn’t authorize.

I'm covered under TRICARE.

For active-duty military enrolled in Medicare, TRICARE pays for Medicare-covered services or items, and Medicare pays second

For inactive-duty military, Medicare pays first for Medicare-covered services and TRICARE may pay second.

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

Get more information on TRICARE.

I have coverage under the Federal Black Lung Program.

For 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.

The Federal Black Lung Program pays first for any health care for black lung disease covered under that program. 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 40742-8302
1-800-638-7072

If the Federal Black Lung Program won't pay your bill, ask your doctor or other health care provider to send Medicare the bill. Ask them to include a copy of the letter from the Federal Black Lung Program that says why it won’t pay your bill.

I have COBRA continuation coverage.

If you have Medicare because you’re 65 or over or because you're under 65 and have a disability other than 

End-Stage Renal Disease (ESRD)

, Medicare pays first.

If you have Medicare based on ESRD, COBRA continuation coverage pays first. Medicare pays second to the extent COBRA coverage overlaps the first 30 months of Medicare eligibility or entitlement based on ESRD.

Find out more in 7 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. It may include the rules about who pays first. You can also call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 (TTY: 1-855-797-2627).

Note 

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 to 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.

Note
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 lawyer haven't reported your settlement, judgment, award or other payment to Medicare, call the 

Benefits Coordination & Recovery Center (BCRC)

 at 1-855-798-2627 (TTY: 1-855-797-2627).

The BCRC will gather information about any conditional payments Medicare made related to your settlement, judgment, award or other payment. If you get a payment, you or your lawyer should call the BCRC. The BCRC will calculate the repayment amount (if any) on your recovery case and send you a letter requesting repayment.