Medicare: Who Pays When !

Medicare: Who Pays First? 

 

Compliments to our friends at Benefit Mall:

 
There are a couple of different scenarios whereby an employee who is covered by both Medicare and the employer’s group health plan may encounter a dilemma as to which pays a claim first. Typically, this is a classic “coordination of benefits” that can sometimes cause confusion if not handled in a timely manner.

For employers with less than 20 employees, in a large majority of cases, Medicare is the primary payer of the claim, followed by the group health plan.

For Example, billed amount $500, Medicare allowed amount $300, Part B pays 80% of $300 = $240, group medical plan will pay the co-insurance amount of the $60 balance of the allowed amount.

Once an employee turns 65 and they are covered by Medicare A or B, they can no longer contribute to the HSA. If they are on Medicare, however, they can use funds to reimburse 213(d) expenses. They do not lose their money.

Scenario	Primary Payer	Secondary Payer
Employer with 20+ employees	Employer	Medicare
Employer with fewer than 20 employees	Medicare	Employer
On spouse's insurance and employer has 20+ employees	Employer	Medicare
On spouse's insurance and employer has fewer than 20 employees	Medicare	Employer
Retiree from non-federal job with health insurance from former employer	Medicare	Employer
Retired and spouse's employer's plan for business with fewer than 20 employees	Medicare	Employer
Retired and spouse's employer's plan for business with 20+ employees	Employer	Medicare
Retired federal employee	Medicare	Federal Employees and Health Benefits Program
TRICARE*	See below
COBRA	Medicare	COBRA
Medicaid	Medicare	Medicaid
Under 65, disabled and have coverage through a family member's employment and employer has 100+ employees	Employer	Medicare

*For TRICARE, there are different scenarios that exist which will determine who pays first:

• For active-duty military personnel enrolled in Medicare, TRICARE pays first for the Medicare-covered services and Medicare pays second.
• For inactive military personnel enrolled in Medicare, Medicare will be the primary payer and TRICARE may pay as the secondary payer.