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When Is Medicare Coverage Secondary?

For those who have more than one health insurance carrier, each type of coverage is referred to as a “payer.” When there is more than one payer, there are rules that are in place that coordinate which of the payers will pay out the benefits first, and which will pay the remainder of the balance.

The first, or “primary” payer, will pay what it owes on your claim. It will then send the remainder of the claim to the second, or “secondary” payer. In some cases, there may also be a third payer.

Whether Medicare is the primary or the secondary payer will depend upon a number of different factors, including the situations that are listed on the following chart. Typically, if you have Medicare, as well as other health insurance coverage, the primary and secondary (and possibly any additional) payers will pay out the benefits as follows:

If you have retiree insurance (insurance from former employment):Medicare pays first.
If you are age 65 or older, you have group health plan coverage that is based on your or your spouse’s current employment, and the employer has 20 or more employees:Your group health plan pays first.
If you are age 65 or older, you have group health plan coverage that is based on your or your spouse’s current employment, and the employer has less than 20 employees:Medicare pays first.
If you are under age 65 and you are disabled, you have group health plan coverage that is based on your family member’s current employment, and the employer has 100 or more employees:Your group health plan pays first.
If you are under age 65 and you are disabled, you have group health plan coverage that is based on your or a family member’s current employment, and the employer has less than 100 employees:Medicare pays first.
If you have Medicare due to having End Stage Renal Disease (ESRD), which is permanent kidney failure that requires dialysis or a kidney transplant:Your group health insurance plan will pay first for the first 30 months after you become eligible to join Medicare. Medicare will then pay first following this 30-month period.

It is important to note that in some instances, if you are enrolled in an employer sponsored health plan, your employer may join with other employers or unions in order to form a multiple employer plan. If this occurs, then only one of the employers or unions in the multiple employer plan has to have the required number of employees for the group health plan to pay first.

If you are enrolled in more than one form of health insurance coverage, it will be important to let all of your doctors, hospitals, and / or other health care providers know about this, as well as any pharmacies where you purchase prescription medications in order to avoid delays, as well as to ensure that your bills are sent to the correct payers, and in the correct order.

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