Primary Or Secondary Payer in Medicare

Primary Or Secondary Medicare Payer Insurance

As we age, many of us will eventually be faced with the decision of whether or not to enroll in Medicare. For those who are still working, this decision is often complicated by the fact that they may have employer-sponsored health insurance. So, what should you do if you have both Medicare and another type of health insurance?

The answer to this question depends on a few factors, including the type of health insurance you have and whether or not you are still working. If you are still working and have employer-sponsored health insurance, your employer’s insurance is typically the primary payer, and Medicare will be the secondary payer. This means that your employer’s insurance will pay first on any claims, and Medicare will only pay if your employer’s insurance doesn’t cover the entire claim.

However, there are a few exceptions to this rule. If you are enrolled in Medicare Part A (hospital insurance) and/or Part B (medical insurance), your employer’s insurance is the secondary payer only if your employer has 20 or more employees. If your employer has fewer than 20 employees, Medicare is the primary payer.

In addition, if you are enrolled in Medicare Part C (Medicare Advantage) or Part D (prescription drug coverage), your employer’s insurance is always the secondary payer, regardless of the size of your employer.

Finally, it’s important to note that if you are no longer working, your employer-sponsored health insurance will no longer be the primary payer. In this case, Medicare will be the primary payer, and your former employer’s insurance will be the secondary payer.

So, what does all of this mean for you? If you have Medicare and another type of health insurance, it’s important to know which insurer is the primary payer and which is the secondary payer. This will help you make the best decision for your situation.

Let’s dive in deeper but first, let’s talk about the basics.

What is Medicare?

Medicare is a federal government-sponsored health insurance program that provides coverage to eligible individuals aged 65 and over.

The program is jointly administered by the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration (SSA).

Medicare consists of four parts:

  1. Part A (hospital insurance),
  2. Part B (medical insurance),
  3. Part C (Medicare Advantage), and
  4. Part D (prescription drug coverage).

Many older adults stay on Original Medicare and obtain a Medicare supplement plan.

Checklist Difference Between Medigap and Advantage Plans

What are the Different Types of Medicare Plans?

There are four different types of Medicare coverage: Original Medicare, Medicare Advantage, Medicare Part D, and Medicare Supplement Insurance.

Original Medicare is the federal government-run health insurance program for seniors and people with disabilities. It includes Part A (hospital insurance) and Part B (medical insurance). Part A covers inpatient hospital care, while Part B covers outpatient medical care, such as doctor visits and lab tests.

Medicare Advantage is a private health insurance alternative to Original Medicare. It includes all the benefits of Original Medicare, plus extra benefits like dental, vision, and prescription drug coverage.

Medicare Part D is a prescription drug plan that helps cover the cost of medications.

Medicare Supplement Insurance is a type of private health insurance that helps cover the costs of deductibles, coinsurance, and copayments not covered by Original Medicare.

Now that we have discussed the basics, let us dive into Primary and Secondary Payer questions.

What is the Difference Between Primary and Secondary Payers in Medicare

There are two types of payers in Medicare: primary and secondary. 

The primary payer is responsible for paying the Medicare-approved amount for covered services. 

The secondary payer may pay some or all of the remaining balance for covered services.

How to change Medicare from Primary to Secondary Payer?

It is possible to change Medicare from Primary to Secondary Payer, but it requires some effort on your part. First, you need to contact your local Medicare office and explain your situation. They may be able to help you change your status.

If you are not satisfied with the response you receive, or if you are unable to get in touch with your local Medicare office, you can also contact the Medicare Rights Center. 

The Medicare Rights Center is a national consumer service organization that can help you understand your rights and options when it comes to Medicare.

Once you have been in touch with the appropriate people, you will need to fill out a form to change your Medicare status. This form is available on the Medicare website. Once you have completed the form, you will need to submit it to the address listed on the form.

It may take a few weeks for your request to be processed, but once it is, you should receive a letter in the mail confirming that your Medicare status has been changed.

What Happens when I Drop my Private Health Insurance?

If you drop your private health insurance, Medicare becomes your primary insurer. If you have both Medicare and a private plan that covers doctors’ office visits, hospitalization, or other services but not prescription drugs, Medicare becomes your secondary insurer.


Are there any Exceptions that Affect Whether Medicare can be your Primary or Secondary Coverage?

The answer to this question is a little more complicated than a simple yes or no. There are several exceptions that can affect whether Medicare is your primary or secondary coverage.

For example, if you are eligible for Medicare and get services outside of your network, neither Medicare nor your insurance plan will pay.

Another exception occurs when you have a group health plan and become eligible for Medicare due to end-stage renal disease. In this case, the group health plan pays first before Medicare takes over as the primary payer.

There are also times when Indian Health Service provides healthcare services to patients with a tribal group health plan; in these cases, Indian Health Service acts as the primary payer first before turning into secondary coverage when it comes time to claim benefits from Medicare.

If you go to a VA location for care, the VA benefits will cover the expenses – even if you’re not retired from military service.

And finally, if you go to a non-VA facility but haven’t been authorized for treatment on VA grounds, your Medicare coverage will kick in and act as secondary insurance.

Where can I get help finding out whether Medicare is Primary or Secondary to my other insurance?

You can check in with your private insurance company to see if Medicare is your primary or secondary insurance or call Medicare directly and ask how they have your insurance set up.

If you have an employer or union plan, your existing plan may be the primary payer for health care expenses before Medicare does.

Your Medicare supplement plans is always secondary to Original Medicare and cover deductibles, copays, and coinsurance that Medicare doesn’t.

You can talk with one of our licensed Medicare agents who can help you find the right plan for your needs at 562-735-3553.

What's a Conditional Payment?

A conditional payment is a type of insurance payment that happens when one company pays first, and then another company pays second. This usually occurs when you have more than one type of insurance coverage.

For example, if Medicare is your secondary insurance and your group health plan is your primary insurance, Medicare will make a conditional payment to cover the costs that your group health plan doesn’t pay. 

This means that you may have to repay Medicare later on if you receive any other payments related to the bill, such as a settlement or judgment.

It’s important to understand how conditional payments work so that there are no surprises down the road.

Be sure to check with both Medicare and your group health plan to see what services are covered under each policy before you travel or get treatment outside of the network.

Can you use Medicare while you are Working?

If the employer has fewer than 20 employees, they must sign up for Medicare during their initial enrollment period; however, if the company employs more than 20 people, then their employees are not required to sign up for Medicare.

There are also penalties for not purchasing a Medicare Part D plan (the prescription drug plan) if you do not have creditable prescription drug coverage through your employer or on your own.

Medicare is Primary

When is Medicare the Primary Payer?

There are many situations where Medicare is the primary payer. These include when a person:

  • Retires and has a disability that’s not ESRD
  • Works and has fewer than 100 employees
  • Participates in a multiemployer insurance plan

In all of these cases, Medicare will become the primary payer after a coordination period. During this time, both insurers will share responsibility for payment. However, if you’re covered under a group health plan or retiree coverage, Medicare becomes the secondary payer.

If your employer participates in a multiemployer insurance plan, then Medicare will usually be the secondary payer after the coordination period. This is because employers who participate in these plans agree to follow certain rules about which insurer pays first.

If you have questions about whether your plan follows these rules, contact your benefits administrator or check with [the Centers for Medicare & Medicaid Services (CMS)].

If Medicare doesn’t get their money back within 120 days, they may make a conditional payment to cover it and then later recover any payments that should have been made by the primary payer. So remember: always keep track of your receipts and submit them to both insurers!

Final Thoughts on Primary vs Secondary Payer:

In conclusion, the primary and secondary payers in Medicare depend on a few factors, including the type of health insurance you have and whether or not you are still working. 

If you are still working and have employer-sponsored health insurance, your employer’s insurance is typically the primary payer, and Medicare will be the secondary payer. However, there are a few exceptions to this rule.

Talk with one of our Medicare insurance agents at Integrity Now Insurance Brokers and we will help you with your Medicare questions.  We service all 50 US States.  Reach out to us today!