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When Can Medicare be a secondary payer?

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Medicare payment usually works seamlessly. You generally pay a coinsurance amount or copayment and don’t have to worry about filing a Medicare claim. But if you have other health insurance besides Medicare, then Medicare might be a secondary payer. Let’s take a look at how this works.

What does it mean to be a secondary payer?

When Medicare (or a Medicare coverage option, such as a Medicare Advantage plan) isn’t your only health insurance, then Medicare and your other insurance use “coordination of benefits” to decide who pays first.

The primary payer (the one who pays first) pays its portion of covered medical expenses first. Then the secondary payer pays its share of what the primary payer didn’t pay. Sometimes there might be a third payer as well. You might have to pay the balance of what the insurers, including Medicare, didn’t pay.

When is Medicare the secondary payer?

If you’re enrolled in Medicare, then Medicare coordinates benefits with other insurance that you may have. Whether Medicare is the secondary payer or primary payer depends on your situation. Here are a few examples of when Medicare might be a secondary payer:

You’re covered through an employer group plan – yours or your spouse’s – and the employer has at least 20 employees. Usually Medicare is the secondary payer.

You’re under 65 and retired, and you have a disability that’s not end-stage renal disease (ESRD). Your spouse is still working, and you’re covered under your spouse’s group plan. Your spouse’s employer has at least 20 employees, or has a multiple-employer group plan.

You’re eligible for Medicare because you have end-stage renal disease (ESRD) and you’re covered by a group plan. There’s a coordination period of about 30 months after you’re eligible for Medicare, when Medicare is the secondary payer.

When is Medicare the primary payer?

You’re under 65 and retired, and you have a disability that’s not end-stage renal disease (ESRD). You have health insurance through your former employer.

  • If you’re still working and your employer has fewer than 100 employees, Medicare will usually pay first. However, Medicare might be the secondary payer if your employer participates in a multi-employer group insurance plan.

In general, if you’re still working and your employer has fewer than 20 employees, Medicare pays first. However, Medicare might be the secondary payer if your employer participates in a multi-employer group insurance plan.

You’re eligible for Medicare because you have end-stage renal disease (ESRD) and you’re covered by a group plan. After a coordination period of about 30 months, that Medicare generally becomes the primary payer.

Is Medicare the secondary payer? It depends on your coverage

Please note that there are many different situations where you may have another type of coverage besides Medicare. Those listed above are just a few examples.

If you have questions, or to report changes in your health insurance coverage, contact Medicare’s Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 (TTY: 1-855-797-2627) between 8:00 AM and 8:00 PM Eastern time Monday through Friday.

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