How Medicare works with other insurance

• If the employer has 20 or more employees, then the group health plan pays first, and Medicare pays second. 

  If the
  group health plan
  didn’t pay all of your bill, the doctor or health care provider should send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn’t cover.

• Employers with 20 or more employees must offer current employees 65 and older the same health benefits under the same conditions that they offer employees under 65. If the employer offers coverage to spouses, it must offer the same coverage to spouses 65 and older that they offer to spouses under 65.
• If the employer has less than 20 employees and isn’t part of a multi-employer or multiple employer group health plan, then Medicare pays first, and the group health plan pays second.
• If the employer has less than 20 employees, the group health plan pays first, and Medicare pays second if both of these conditions apply:
  • The employer is part of a multi-employer or multiple employer group health plan
  • At least one of the other employers has 20 or more employees

Check with your plan first and ask if it will pay first or second.

It’s possible that neither the plan nor Medicare will pay if you get care outside your plan’s network. Before you go outside the network, call your plan to find out if it will cover the service.

If you’re 65 or older, Medicare pays first unless both of these apply: 

• You have coverage through an employed spouse.
• Your spouse’s employer has at least 20 employees.

Call your employer’s benefits administrator for more information.

Your spouse’s plan pays first, and Medicare pays second when all of these conditions apply:

• You’re retired, but your spouse is still working.
• You’re covered by your spouse’s group health plan coverage.
• Your spouse’s employer has 20 or more employees, or has less than 20 employees, but is part of a multi-employer plan or multiple employer plan.

If the group health plan doesn’t pay all of a bill, the doctor or health care provider should send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn’t cover.

If you’re not currently employed, Medicare pays first, and your group health plan coverage pays second.

• If the employer has 100 or more employees, then your family member’s group health plan pays first, and Medicare pays second.
• If the employer has less than 100 employees, but is part of a multi-employer or multiple employer group health plan, your family member’s group health plan pays first and Medicare pays second.
• If the employer has less than 100 employees, and isn’t part of a multi-employer or multiple employer group health plan, then Medicare pays first, and your family member’s group health plan pays second. 

When you’re eligible for or entitled to Medicare because you have ESRD, your group health plan pays first, and Medicare pays second during a coordination period that lasts up to 30 months. You can have group health plan coverage or retiree coverage based on your employment or through a family member.

After the coordination period ends, Medicare pays first and your group health plan (or retiree coverage) pays second. 

Whichever coverage paid first when you originally got Medicare will continue to pay first. You can have group health plan coverage or retiree coverage based on your employment or through a family member.

When you’re eligible for or entitled to Medicare due to ESRD, COBRA pays first, and Medicare pays second during a coordination period that lasts up to 30 months after you’re first eligible for Medicare. After the coordination period ends, Medicare pays first.

• If you have non-tribal group health plan coverage through an employer who has 20 or more employees, the non-tribal group health plan pays first, and Medicare pays second.
• If you have non-tribal group health plan coverage through an employer who has less than 20 employees, Medicare pays first, and the non-tribal group health plan pays second.
• If you have a group health plan through tribal self-insurance, Medicare pays first and the group health plan pays second. 

No-fault insurance or liability insurance pays first and Medicare pays second.

If the no-fault or liability insurance denies your medical bill or is found not liable for payment, Medicare pays first, but only pays for Medicare-covered services. You’re still responsible for your share of the bill (like
coinsurance
, a
copayment
or a
deductible
) and for the cost of services Medicare doesn’t cover.

If your provider knows you have a no-fault or liability insurance claim, they must try to get paid by the insurance company before billing Medicare. If the insurance company doesn’t pay the claim promptly (usually within 120 days), your provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then will recover any payments the primary payer should have made later.

If Medicare makes a
conditional payment
, and you get a settlement from an insurance company later, you’re responsible for making sure Medicare gets repaid.

If you file a no-fault insurance or liability insurance claim and Medicare makes a conditional payment, you or your representative should report the claim and payment by calling the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627). 

The Benefits Coordination & Recovery Center:

• Gathers information about conditional payments Medicare makes.
• Calculates the final amount owed (if any) on your recovery case.
• Send you a letter asking for repayment.

If you get a settlement, judgment, award or other payment, you or your representative should contact the Benefits Coordination & Recovery Center.

Workers’ compensation
pays first for services or items related to the workers’ compensation claim. Medicare may make a conditional payment if the workers’ compensation insurance company denies payment for your medical bills for 120 days or more, pending a review of your claim.

Find out more about how settling your claim affects Medicare payments.

If you have (or can get) both Medicare and Veterans’ benefits, you can get treatment under either program. Generally, Medicare and the U.S. Department of Veterans Affairs (VA) can’t pay for the same service or items. Medicare pays for Medicare-covered services or items. The VA pays for VA-authorized services or items. Each time you get health care or see a doctor, you must choose which benefits to use.

If the VA authorizes services in a non-VA hospital, but didn’t authorize all of the services you get during your hospital stay, then Medicare may pay for any Medicare-covered services the VA didn’t authorize.

If you’re on active duty and enrolled in Medicare, TRICARE pays first for Medicare-covered services or items, and Medicare pays second. If you’re not on active duty, Medicare pays first for Medicare-covered services, and TRICARE may pay second.

If you get items or services from a military hospital or any other federal health care provider, TRICARE pays first.

Get more information on TRICARE.

For any health care related to black lung disease, the Federal Black Lung Program pays first as long as the program covers the service. Medicare won’t pay for doctor or hospital services covered under the Federal Black Lung Program.

Your doctor or other health care provider should send all bills for the diagnosis or treatment of black lung disease to:

Federal Black Lung Program
PO Box 8302
London, KY 40742-8302

For all health care not related to black lung disease, Medicare pays first, and your doctor or health care provider should send your bills directly to Medicare.

If the Federal Black Lung Program won’t pay your bill, ask your doctor or other health care provider to send Medicare the bill. Also ask them to include a copy of the letter from the Federal Black Lung Benefits Program explaining why they won’t pay your bill.

If you have questions about the Federal Black Lung Program, call 1-800-638-7072.

If you have Medicare because you’re 65 or over or because you’re under 65 and have a disability (not 
End-Stage Renal Disease (ESRD)
), Medicare pays first.

If you have Medicare due to ESRD, COBRA pays first and Medicare pays second during a coordination period that lasts up to 30 months after you’re first eligible for Medicare. After the coordination period ends, Medicare pays first. 

Find out more about COBRA coverage. 

If you have Medicare and more than one other type of insurance, check your policy or coverage information for rules about who pays first. You can also call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627).