Medicare, a federal health insurance program, is meant to provide comprehensive health coverage for qualifying individuals. This includes people over the age of 65, those with disabilities, or those with end-stage renal disease. Many people ask the question, “Is Medicare primary or secondary insurance?”
In this article, we will discuss everything you need to know about Medicare coverage. We’ll also examine how it works with other coverage plans such as group health plans and retiree insurance.
To begin, primary coverage is the insurance plan that pays first for qualifying medical expenses. For those who only have Medicare, that plan will be their primary insurer. However, you can also purchase a secondary insurance plan. This can provide benefits that your primary insurer does not offer. In addition, it can help ease healthcare costs.
With two health coverage plans, a coordination of benefits will occur. Your primary coverage plan, either Medicare or private, will pay for covered medical expenses. Then, your secondary plan will cover additional costs. Both insurance plans will communicate with each other to ensure there aren’t duplicate payments.
When Medicare acts as secondary insurance, it is commonly known as Medicare Secondary Payer. The goal is to ensure that individuals receive proper coverage from their primary insurer. Many times, Medicare may make a conditional payment. As the policyholder, there are steps you should take to confirm benefits and coverage status. For example, you should promptly respond to MSP claims letters and notify the BCRC (Benefits Coordination & Recovery Center) of any changes in your health insurance plans. In fact, the BCRC will recover any qualifying conditional payment made by Medicare.
To qualify for Medicare, one must meet certain eligibility requirements. First, they must be over 65 years old and have paid at least 10 years of Social Security taxes. Also, individuals may qualify if they have a disability or end-stage renal disease (ALS or permanent kidney failure.) There are several different scenarios where Medicare will act as your primary insurer.
Medicare has a plethora of benefits (inpatient/outpatient services, prescription drug coverage) and it is essential to know what plans may be available. You should consider speaking with a licensed insurance agent as they can provide accurate information on how Medicare works with retiree insurance.
To help pay for health care expenses, individuals can enroll in a Medicare Supplemental Plan, more commonly known as Medigap. To be eligible, you must already be enrolled in Original Medicare (Parts A and B). Also, you can’t have both Medigap and Medicare Advantage at the same time. Understandably, if you are receiving Medicare supplemental coverage, Medicare must be your primary coverage plan.
Depending on the retiree insurance plan, individuals may no longer receive health coverage if they qualify for Medicare. In this scenario, Medicare must act as the primary insurance provider. However, certain plans do offer coverage, even if the retiree is Medicare-eligible. When this occurs, the retiree insurance plan typically acts as secondary insurance.
For working individuals who are Medicare-eligible, the size of their company will determine who acts as the primary payer. If you work for a company with less than 20 employees, Medicare becomes your primary coverage. It is important to enroll in Medicare once you turn 65 as multiple coverage plans will lower your out-of-pocket costs.
Individuals under the age of 65 may enroll in Medicare if they have a disability. Furthermore, Medicare will act as the primary insurer if your employer-sponsored group health plan has fewer than 100 employees. If you are no longer working due to disability, Medicare will pay first, regardless of company size.
An End-Stage Renal Disease such as permanent kidney failure or ALS (Lou Gehrig’s Disease) is an automatic qualification for Medicare. Individuals without a group health insurance plan will receive primary coverage through Medicare. Furthermore, if you have been Medicare eligible (end-stage renal disease) for at least 30 months, they will pay first, regardless of group health plan status.
If you are no longer working at your current job, you can retain health coverage through COBRA (Consolidated Omnibus Budget Reconciliation Act.) In addition, employees who are recently Medicare eligible also qualify. While this is a great option to keep benefits, it can be quite costly. You may be required to pay your full monthly premium plus an additional 2% service charge. To save costs, you can choose to keep Medicare and not pay for COBRA. With only one insurance plan, Medicare will be your primary payer, and coordination of benefits will not occur.
For service members, retirees, and their dependents TRICARE can provide retiree coverage plans. Individuals over the age of 65 who are enrolled in Medicare Parts A and B will receive TRICARE For Life. Medicare will act as the primary payer and TRICARE will provide benefits for coinsurance, copayments, and monthly deductibles. In addition, TRICARE will cover expenses for services offered by military hospitals.
Medicaid is a federal and state health program that aims to help individuals pay for health care expenses. To qualify, one must be within 133% of the federal poverty level. Depending on your state of residence, benefits may vary. You can have both Medicare and Medicaid, with Medicare acting as your primary insurance.
There are scenarios when Medicare becomes your secondary insurer. While Medicare has plenty of benefits, it does not cover everything. In fact, your retiree coverage or marketplace insurance plan may provide additional benefits. Understandably, managing the out-of-pocket costs for healthcare plans, such as prescription drug coverage, can be worrisome. To mitigate these concerns, you may want to purchase supplemental coverage and speak with an experienced insurance agent.
If you are receiving worker’s compensation benefits that cover health expenses.
Medicare becomes your secondary insurer if:
You are above 65 and receive insurance from your or your spouse’s group health plan
The company must have less than 20 employees
You are under 65 with a disability and receive primary coverage from you or your spouse’s employer. Also, the company must have over 100 employees
It is important to note that Medicare and Marketplace Healthcare do not work together. After enrolling in Medicare, you can not sign up for a Marketplace insurance plan. In addition, once you enroll in Medicare Advantage, they will act as your primary payer, not Original Medicare. If your primary insurer fails to promptly pay for covered services, Medicare would make a conditional payment.
In general, Medicare will work with employer-based group health and retiree coverage plans. By speaking with a qualified insurance agent, you can better understand different coverage plans and find one that works best for you.
A Secondary insurer, like retiree coverage, can provide benefits that aren’t offered by Medicare. In particular, they can offer benefits for prescription drug coverage. Also, supplemental insurance like Medigap can help pay for out-of-pocket costs such as monthly deductibles, copayments, and coinsurance. You can receive a quote online to learn more about potential costs.
Medicare Part D helps provide prescription drug coverage for enrolled members. Typically, it will act as the primary payer if you are retired or if your group health plan has less than 20 employees.
Yes, Medicare can be both a primary and secondary insurer. This will depend entirely on your age, employment status, or your spouse’s group health plan. Typically, Medicare is your primary payer, even if you have retiree insurance. Also, they may give a conditional payment when Medicare acts as secondary insurance.
Secondary insurance is a separate health plan that is employer-sponsored. With two coverage plans, a coordination of benefits will occur to decide which insurance company pays first. For example, your secondary insurance may help pay for prescription drug coverage. Supplemental Insurance, like Medigap, is meant to help pay for expenses not fully covered by the primary payer.
No, any provider that accepts Medicare or Medicaid can not bill patients who are Qualified Medicare Beneficiaries.
No, you are not required to have a secondary insurer with Medicare. However, secondary or supplemental insurance can help cover costly medical expenses. When this occurs, a coordination of benefits will take place.
For more information about primary and secondary insurance, please contact us at Health Plans of NC. Our phone number is 800-797-0327. Our team of licensed and experienced insurance agents would love to help you.