If you’ve got Medicare and other health coverage, you might be wondering how they mesh together. Figuring out who pays what, when your bills are covered correctly, and who to turn to for assistance is crucial. The insurance world dubs this Coordination of Benefits, where a list of rules—full of “ifs” and “thens”—decides who’s in charge.
So, who pays first?
Medicaid: Medicare, pays first, and Medicaid steps in as the second payer. But if you’ve got Medicare Advantage, a Medicare Supplement, or other insurance, Medicaid becomes the payer of last resort.
Employer Coverage: If your employer’s got 20+ employees, their plan steps up first, and Medicare follows. For smaller teams (less than 20), Medicare takes the lead, and the group plan comes next.
COBRA: If your Medicare stems from a disability other than ESRD (End-Stage Renal Disease), Medicare pays first. But if it’s due to ESRD, COBRA leads the way initially, and Medicare jumps in second during the first 30 months after becoming eligible. After that, Medicare takes the lead.
Retiree Health Plan: If you’re 65 or older, the same rules as Employer Coverage apply. If you’re under 65, disabled, and retired, Medicare leads, and retiree coverage follows.
No-Fault or Liability Insurance: When it’s accident-related services, no-fault/liability insurance is first, then Medicare. For non-accident-related services, Medicare takes the primary payer role.
Workers’ Compensation: Related services to a workers’ compensation claim – it’s the workers’ comp that leads. Medicare might make a conditional payment, which needs repaying when there’s a settlement or other payments.
Veterans’ Benefits: Generally, Medicare and Veteran’s Affairs (VA) don’t cover the same services. Medicare handles its covered services, while the VA manages its authorized services or items.
TRICARE: For active-duty military enrolled in Medicare, TRICARE comes first for Medicare-covered services or items, followed by Medicare. For inactive-duty military, Medicare takes the lead, and TRICARE might follow. For services from a military hospital or federal provider, TRICARE steps up first.
Still puzzled?
Your healthcare providers usually handle this, but having a basic grasp can aid in planning expenses and maximizing insurance perks. Reach out to us for extra guidance anytime!
