Thursday, November 17, 2022

Is Medicare My Primary Or Secondary Insurance

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Private Health Insurance Coverage

Medical Billing:- Medicare as Primary Insurance

Bare minimum private health insurance covers preventative care visits. But it can be customized to include additional coverage at additional cost.

You can choose an all-in-one coverage plan covering hospitalization, medical visits, prescription drug, dental, vision and other types of benefits. Or you can choose different add-ons to get only the ones you need.

And unlike Medicare, private health insurance usually allows you to extend your coverage for other family members.

Medicare And Workers Compensation

Workers compensation always pays first when youre using it alongside Medicare. Thats because workers compensation is an agreement that your employer will pay medical costs if youre hurt at work. In return, you agree not to sue them for damages. Since your employer has agreed to pay, Medicare will not pay until the benefit amount of your workers compensation is completely spent.

However, sometimes a workers compensation case needs to be investigated or proven before its approved. In this case, Medicare will act as a temporary primary payer. When your claim is approved, workers compensation will reimburse Medicare. Youll also be reimbursed for any coinsurance or copayments you made.

Will My Secondary Insurance Pay For My Medicare Deductible And/or Coinsurance

Understand what secondary insurance is, how it applies to Medicare, and if it will cover deductibles and coinsurance for your Medicare costs.

Understanding your Medicare costs can be confusing when there are two or more insurance policies interacting with one another. Read on to learn:

  • What coordination of benefits is when there are two insurance plans.
  • Which coverage pays first when it comes to Medicare and other insurance.
  • What to do when there is still payment due.

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How To Make Medicare The Primary Insurance

Some people have health insurance coverage both from Medicare and some other plan, such as employer-provided health insurance. In some cases, Medicare is the primary payer, which means it is responsible for paying for covered charges before any other plans, which are called secondary payers because they’re responsible only for covered charges left unpaid by the primary payer. In other cases, the other plan is primary and Medicare is secondary. The determination of which plan is primary rests in Medicare regulations and the nature of the plans themselves. If youre in this situation and Medicare is a secondary payer, you can make it primary, but usually only by changing the circumstances of your other coverage.

How Do Medicare And Private Insurance Networks Differ

Nevada Medigap Plans

Original Medicare has the largest network of health care providers in the United States. That means you have the greatest choice of doctors, hospitals and other providers who take Medicare. Private insurance typically has much smaller networks.

With Medicare, you can go to any provider, anywhere in the United States, who accepts Medicare.

Private insurance negotiates contracts with doctors and hospitals within a specific area. These private networks also tend to include fewer doctors and hospitals in network, meaning you have to pay more out of your own pocket if you use those providers unless its an emergency.

Don’t Leave Your Health to Chance

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Why Is Medicare Advantage A Bad Choice

Medicare Advantage can become expensive if youre sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patients choice. Its not easy to change to another plan if you decide to switch to Medigap, there often are lifetime penalties.

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Can You Have Two Health Insurance Plans

Yes, you can have two health plans.

The most common example of carrying two health insurance plans is Medicare recipients, who also have a supplemental health insurance policy, says David Mordo, former national legislative chair and current regional vice president for the National Association of Health Underwriters.

Its also possible that a married couple could have two health insurance plans, even if each spouse is covered through a health insurance plan at their workplace.

Theyre both covered under their own policies with their companies, but one of the spouses decides to jump on their spouses plan, Mordo says.

You also might have two health insurance plans if you have health insurance but also receive Medicaid coverage. Or, perhaps you are under the age of 26 and have group coverage both through an employer and your parents health insurance.

Other examples of when you might have two insurance plans include:

  • An injured worker who qualifies for workers compensation but also has his or her own insurance coverage.
  • A military veteran who is covered by both Veterans Administration benefits and his or her own health plan.
  • An active member of the military who is covered both by military coverage and his or her own health insurance.

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Should I Take Medicare Part B

You should take Medicare Part A when you are eligible. However, some people may not want to apply for Medicare Part B when they become eligible.

You can delay enrollment in Medicare Part B without penalty if you fit one of the following categories.

Employer group health plans may cover items normally not covered by Medicare Part B. If so, and you meet one of the categories above or below, then you may not need to enroll in Medicare Part B and pay the monthly premium.

If you are:

  • a spouse of an active worker
  • a disabled, active worker
  • a disabled spouse of an active worker

and choose coverage under the employer group health plan, you can refuse Medicare Part B during the automatic or initial enrollment period. You wait to sign up for Medicare Part B during the special enrollment period, an eight month period that begins the month the group health coverage ends or the month employment ends, whichever comes first.

You will not be enrolling late, so you will not have any penalty.

If you choose coverage under the employer group health plan and are still working, Medicare will be the secondary payer, which means the employer plan pays first.

If the employer group health plan does not pay all the patients expenses, Medicare may pay the entire balance, a portion, or nothing. An employer group health plan must be primary or nothing.

How Do You Determine Which Health Insurance Is Primary

Medicare as a secondary insurance

Determining which health plan is primary is straightforward: If you are covered under an employer-based plan, that is primary, Mordo says.

If you also were covered under a spouses plan, that would be secondary, he adds.

In certain situations, seniors who are 65 and still working may be covered under their employers plan and eligible for Medicare.

Depending on the size of the employer, Medicare can be primary or Medicare can be secondary, Mordo says.

If the employer has 20 or more employees, the employers health plan will be primary, and Medicare will be secondary.

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Can Medicare Be Changed From Primary Payer To Secondary Payer Depending On The Care You Need

Typically, no. Your primary and secondary coverage depends on how you get insurance, not on the type of healthcare that you need. That said, you can make Medicare your primary insurer by dropping your private insurance altogether. Or Medicare could be secondary, if you start a new job with group health insurance.

Once you end your private health insurance, youll enter Medicares 8-month special enrollment period, and youll have to sign up promptly to avoid penalties.

Example: Primary And Secondary Payer Coordination

You visit your doctor for a normal checkup. Your doctors office bills both Medicare and the group insurance you have through your employer for the visit. Your group insurance is the primary payer because youre over 65 and your employer has more than 20 employees, so your group health plan pays whatever their standard rate for a doctors office visit is. Medicare is the secondary payer, so they pay whatever charges are left over. If there happens to be any amount left after both Medicare and your group insurance pay what they will cover, you may have to pay the remainder to your doctors office.

Medicare offers a helpful guide on that covers different situations and how Medicare works with your other insurance. You can also call the Medicare Benefits Coordination & Recovery Center Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays, at toll-free lines: 1-855-798-2627 if you have questions about who pays first.

To learn more about Medicare, visit, check the Medical Mutual website, or like our to see the latest updates in this series. You can also for more details.

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How Does Medicare Work With My Current Employer Insurance

Dear Marci,

I will turn 65 soon and be eligible for Medicare. I am still working and receive health insurance from my employer. If I sign up for Medicare, how will it work with my current employer-based insurance?


Dear Marco,

This is a common question. As more people continue to work past age 65 and receive employer health benefits, they have questions about Medicare coverage. Learning about how Medicare works with your current employer insurance can help you decide if you want to sign up for Medicare when you become eligible. Note that when we say current employer insurance, we mean insurance from either your or your spouses job.

The first thing to think about is whether Medicare will to your current employer insurance. Medicare paying primary means that Medicare pays first on health care claims, and your employer insurance pays second on some or all of the remaining costs. Medicare paying secondary means that your employer insurance pays first, and Medicare pays on some or all of the remaining costs.

Medicare works with current employer coverage in different ways depending on the size of the employer. For people who are eligible for Medicare because they are 65 or older, Medicare pays primary if the insurance is from current work at a company with fewer than 20 employees. This is called a small group health plan. Medicare pays secondary if the insurance is from current work at a company with more than 20 employees. This is called a Group Health Plan .


If Your Or Your Spouse’s Employer Has 20 Or More Employees Then The Group Health Plan Pays First And Medicare Pays Second

What is Medicare Secondary Payer?

If the

didn’t pay all of your bill, the doctor or

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.

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Secondary And Primary Insurers

The payment structure is one factor that can help you decide whether it is worth it to continue to receive employee group coverage. After age 65, your group insurance can either become your primary or secondary insurer. Whichever it becomes can be based on your companys size or other factors.

If your group plan remains your primary insurer, your existing coverage will continue to pay for its benefits, as it would normally. If your employer has coverage that is primary, you generally do not need to sign up for Medicare Part B . You may still want the extra coverage from Medicare, so it is best to look into exactly what benefits you could be getting from both insurances before you make a decision.

If your group plan becomes your secondary insurer, it pays second. The secondary plan covers all or some of the health care expenses that the primary insurer has not paid. For example, a secondary insurer could pay the 20 percent coinsurance on a service covered by Original Medicare. If you have secondary insurance and do not have primary insurance, you risk having very little coverage for necessary medical services.

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How Does Medicaid Coordinate With Other Insurance

Medicaid acts as the payer of last resort when a beneficiary has an employer-based or other private commercial insurance plan. This means Medicaid will be the last plan to contribute to a medical bill and may pick up copayments and coinsurances in similar fashion to how Medicaid works with Medicare.

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Are Two Insurers Beneficial

When someone has two insurers, they benefit from broader healthcare coverage. Each insurer could cover services that the other does not, such as dental care, eye examinations, or alternative health therapies.

As an example, a primary insurer may offer prescription drug coverage, meaning that a person with original Medicare would not need a separate Medicare Part D plan or a Medicare Advantage plan that includes prescription drug coverage. This could lower a personâs overall healthcare costs.

If someone needs to stay in a hospital or a nursing facility for a long time, they may find it beneficial to have two insurers. For example, an individualâs primary insurer would pay up to their limits, and Medicare Part A benefits would kick in much later, extending the coverage period.

Will Medicare Ever Be The Secondary Payer

Is Medicare Primary or Secondary?

Yes. Situations exist in which Medicare may be a secondary payer. These situations include:

  • Accidents where there is no fault or liability are involved, such as a car accident
  • Group plans where you, or your spouse, have an employer with more than 20 employees
  • If youre covered under workers compensation due to job-related injury.
  • If youre on active duty and enrolled in Tricare, Medicare is secondary

Medicare offers a quick guide for the most common situations where you may have a question about who is the primary payer. If you have questions about Medicares coordination with other insurances, call the Benefits Coordination & Recovery Center at 798-2627. You will also want to make sure you tell your providers about any changes or additional coverages you may have when you get services.

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Medicare Secondary Claim Development Questionnaire

The Medicare Secondary Claim Development Questionnaire is sent to obtain information about other insurers that may pay before Medicare. When you return the questionnaire in a timely manner, you help ensure correct payment of your Medicare claims.

This questionnaire is mailed when a claim is submitted to Medicare with an explanation of benefits attached, a self-report is made by you or your attorney identifying a Medicare Secondary Payer situation, or an insurer submits MSP information to a contractor, or the BCRC. This questionnaire asks:

  • If you have other health insurance or coverage based upon your current employment
  • If you are receiving black lung benefits, workers’ compensation benefits, or treatment for an injury or illness for which another party could be held liable, or are covered under automobile no-fault insurance and
  • If you have other health insurance or coverage based upon a family member’s current employment.

You may access a sample Medicare Secondary Claim Development questionnaire in the Downloads section at the bottom of this page. Note that the questionnaire you receive may appear slightly different depending on the reason you are entitled to Medicare. If assistance is needed in completing the questionnaire, the BCRC should be contacted. For BCRC contact information, please click the Contacts link in the Related Links section below.

Determining Which Plan Is Primary

If you or your dependents are covered by more than one Benefit Plan, United will apply theterms of your Employer Plan and applicable law to determine that one of those Benefit Plans will be the Primary Plan. The Primary Plan is the Benefit Plan that must pay first on a claim for payment of covered expenses. The Primary Plan is the plan that must determine its benefit amount as if no other Benefit Plan exists. Other Benefit Plans that cover you or your dependent are Secondary Plans. Any Secondary Plan may pay certain benefits in addition to those paid by the Primary Plan. For example, if your spouse covers you under her Employer Plan and you are also covered under a different Employer Plan, your Employer Plan is the Primary Plan for you, and your spouses Employer Plan is the Secondary Plan for you.

COB also applies when you or your dependents have health coverage under Medicare, workers compensation or motor vehicle or homeowners insurance. Your Employer Plan will often have a specific section entitled Order of Benefit Determination Rules which sets forth how your Employer Plan identifies the Primary Plan.

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Primary Vs Secondary Medicare Plans

Medicare is primary to a Supplement plan because it pays first. After reaching the limit, your Medigap plan will pay second. Often, secondary insurance will not pay if the primary insurance doesnt pay.

Medigap is not the only type of insurance that can be secondary to Medicare. For example, those with TRICARE For Life have TFL as their secondary plan. A series of rules known as the coordination of benefits decides the order of payment in each case. Sometimes, although rarely, there can be up to three payers.

When Is Medicare Primary

Medicare Secondary Payer (MSP) Overview

For the most part, when you have more than one form of coverage, Medicare is primary. Some examples include having group coverage through a smaller employer, COBRA, being on inactive duty with TRICARE, or Medicaid. Usually, secondary insurance will only pay if the primary insurance paid its portion first.

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