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Can I Have Private Insurance and Medicare

American Senior

How Medicare works with other insurance

In the event you have:

In the case of Medicare and other health insurance coverage (such as a group health plan, retiree coverage, or Medicaid), each type of coverage is referred to as a "payer." When there is more than one payer, a "coordination of benefits" rule determines who pays first. "Primary payers" pay their bills first, and then send the remainder to "secondary payers" (supplemental payers). Occasionally, a third party may be involved.

What it means to pay primary/secondary

  • It is the primary payer's responsibility to pay up to its coverage limits.

  • A secondary insurer pays only if the primary insurer did not cover the costs.

  • There is a possibility that the secondary payer (which may be Medicare) will not cover all the remaining expenses.

  • Medicare Part B may be required before you can receive benefits from your group health plan or retiree coverage.

  • Whenever an insurance company fails to pay a claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. If Medicare makes a conditional payment, it may later recover any payments it should have made to the primary payer.

I have Medicare and:

I am 65 or older and have group health plan coverage through my current employer or my spouse's employer.

  • In a company with more than 20 employees, the group health plan pays first, followed by Medicare. If your group health plan didn't cover all of your bill, your doctor or healthcare provider should submit the bill to Medicare for secondary payment. Medicare and group health plans may not cover all costs. Employers with more than 20 employees must offer the same health benefits to employees 65 and older as to employees under 65. It is the employer's responsibility to offer the same coverage to spouses 65 years and older as to spouses under 65.

  • Medicare pays first, and the group health plan pays second if the employer has fewer than 20 employees.

  • When both conditions are met, Medicare pays first, followed by the group health plan if there are fewer than 20 employees.

  • A group health plan for multiple employers is provided by the employer

  • There is at least one other employer with 20 or more employees

A doctor or health care provider should submit a bill to Medicare for secondary payment if the group health plan doesn't pay all of the bill. Unless Medicare or the group health plan covers the costs, you may have to pay them.

As a retired employee with group health coverage from my former employer, I am under 65, disabled, and disabled. Unless you're currently employed, Medicare pays first, followed by your group health plan. Under 65, disabled, retired, and covered by my family member's current employer's group health insurance.

  • The group health plan of your family member pays first, followed by Medicare if the employer has 100 or more employees.

  • When an employer has less than 100 employees, but he or she is part of a multiemployer group health plan, the group health plan pays first and Medicare pays second.

  • Medicare pays first then your family member's group health plan if the employer has fewer than 100 employees and isn't part of a multiemployer plan.

Due to End-Stage Renal Disease (ESRD), I am covered by Medicare and group health insurance plans (including retiree coverage).

Your group health plan pays first, and Medicare pays second during a coordination period that lasts up to 30 months if you have ESRD. Depending on your employment or a family member's coverage, you can have group health coverage or retiree coverage.

As soon as the coordination period ends, Medicare pays first, followed by your group health plan (or retiree coverage).

I am covered by a group health plan. In the beginning, I got Medicare because I turned 65 or because I was disabled (other than having end-stage renal disease (ESRD)).

In the event that you originally got Medicare first, that coverage will continue to pay first. As a member of a group health plan or a retiree, you may have coverage through your employer or through a member of your family. +Due to End-Stage Renal Disease (ESRD), I have Medicare and COBRA coverage.

The coordination period lasts for 30 months after you become eligible for Medicare due to ESRD, and COBRA pays first, then Medicare. Medicare pays first following the coordination period.

I get health care services from Indian Health Service (IHS) or an IHS provider.

  • Medicare pays second if you have coverage through a non-tribal group health plan through an employer with 20 or more employees.

  • An employer with less than 20 employees with non-tribal group health insurance pays Medicare first, then the non-tribal health insurance.

  • You will receive the first payment from Medicare if you have a tribal self-insurance group health plan.

In the past, I have been involved in an accident involving no-fault or liability insurance.

The first payment is made by no-fault insurance or liability insurance, and the second payment is made by Medicare.

Medicare pays first if your no-fault or liability insurance denies your medical bill or cannot pay, but only for Medicare-covered services. The cost of services Medicare does not cover remains your responsibility (for example, coinsurance, copayments, and deductibles [glossary]).

Before billing Medicare, your provider must try to get paid by your no-fault or liability insurance company. Medicare may bill your provider if the insurance company fails to pay the claim promptly (usually within 120 days). If Medicare makes a conditional payment, it will recover any payments the primary payer should have made.

In the event that Medicare makes a conditional payment and you receive a settlement from an insurance company later, you must make sure Medicare is 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).


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