Is Medicare Primary or Secondary?

Summary: Typically, Medicare coverage will be your primary insurance when you have additional forms of coverage. However, in some instances, Medicare coverage may be secondary. Learn more about when each is your primary or secondary form of coverage. Estimated Read Time: 13 mins

Medicare is always primary when it is your only form of coverage. When you introduce additional insurance to the picture, predetermined coordination of benefits comes into play. This coordination of benefits will determine which form of coverage is primary and which is secondary.

As the names suggest, your primary coverage will pay first, and your secondary coverage will pay after. Medicare, primary or secondary, still offers excellent benefits to seniors, but your benefits depend on which coverage pays for healthcare first. Below, we’ll go over scenarios when Medicare is primary or secondary and when there is no coordination of benefits.

Is Medicare Primary or Secondary to Group Insurance?

When combined with employer-group insurance, Medicare is typically your primary coverage. However, whether Medicare is primary or secondary to group insurance depends on a few factors, such as the size of the employer and the reason for Medicare coverage.

If your employer has less than 20 employees, Medicare is generally considered the primary payer, and your group coverage is secondary. In this case, Medicare pays first for any covered services, and the group insurance plan may cover some of the remaining costs.

If the employer has 20 or more employees, the group insurance plan is usually considered the primary payer while you are still working, and Medicare is secondary.

It’s important to note that Medicare is always the secondary payer for any services or items that it doesn’t cover, such as hearing aids or routine dental care. In these cases, the group insurance plan would be the primary payer.

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Medicare and Group Coverage Through Larger Employer

Many people on Medicare have group insurance through their company or spouse’s employer. This coverage will be your primary insurance if you are still employed through the company providing your insurance and the company employs more than 20 people.

If you have group coverage through an employer or union, you may be able to delay enrolling in Medicare without facing penalties. You can delay enrolling in Medicare Part B, which covers outpatient services if you have creditable group health coverage through your employer or through your spouse’s employer or union.

Creditable coverage means that your group health coverage is expected to pay, on average, at least as much as Medicare Part B would pay. If your group coverage is creditable, you can delay enrolling in Medicare Part B without facing late enrollment penalties. However, it is essential to have confirmation that your coverage is creditable before delaying Medicare benefits.

If your group coverage is not creditable or if you lose your group coverage, you will need to enroll in Medicare Part B during your Initial Enrollment Period or Special Enrollment Period to avoid paying the Part B late enrollment penalty.

Under 65 and Disabled with Larger Employer Group Coverage

If you’re under 65, eligible for Medicare due to a disability, and have group employer coverage through an employer with more than 100 employees, Medicare acts as your secondary payer.

However, it’s important to note that there are some exceptions to this rule. In some cases, if your group health plan is self-insured, meaning the employer bears the risk of paying for healthcare expenses, Medicare may be the primary payer instead. However, this scenario is rare.

Additionally, if you are under 65 and have end-stage renal disease (ESRD), Medicare may be the primary payer for your healthcare expenses, even if you have group health coverage through a larger employer.

It’s also worth noting that even if your group health plan is the primary payer, you can still use your Medicare benefits to help cover some of your healthcare costs. For example, Medicare may cover some services that your group health plan does not, such as skilled nursing care or certain types of durable medical equipment. Plus, if you have prescription drug coverage through your group health plan, you may be able to enroll in a Medicare Part D prescription drug plan to help cover your medication costs.

Medicare Coverage With End-Stage Renal Disease (ESRD)

In most cases, Medicare is the primary payer for individuals with End-Stage Renal Disease (ESRD), regardless of whether they have other health coverage. This means that Medicare would pay first for their healthcare expenses related to ESRD, and any other insurance they have would be secondary.

It’s important to note that ESRD beneficiaries can enroll in Medicare regardless of their age or work status, and they are eligible for all parts of Medicare. Additionally, individuals with ESRD who are on dialysis or have had a kidney transplant may also be eligible for coverage of immunosuppressive drugs under certain conditions, even if they do not have Medicare coverage for other healthcare expenses.

Medicare as Secondary Insurance Outside of Employer Group Coverage

Medicare as secondary insurance isn’t as common, especially for seniors without group coverage from their employer. Nevertheless, there are scenarios when this coordination of benefits becomes effective. Some examples of this include:

• TRICARE
• Receiving Workers’ Compensation
• Federal Black Lung program
• No coordination of benefits

Receiving Workers’ Compensation

With Medicare and workers’ comp, your workers’ compensation policy will pay first if you’re injured or become sick on the job. Thus, Medicare will pay second. Yet, Medicare will pay first for any medical service you receive unrelated to the workers’ compensation claim.

Federal Black Lung Program

If you’re covered under the Federal Black Lung Program, the program is your primary payer, and Medicare will pay second.

No Coordination of Benefits

When there is no coordination of benefits, the policies will not work together or complement one another. Some examples include when you have a Medicare Advantage plan, Medicare and Marketplace insurance, or Veterans (VA) Benefits. Medicare does not coordinate with these healthcare programs.

When is Medicare Primary?

For people with more than one form of coverage, in most cases, Medicare is primary. Some examples of when Medicare pays first include when it coordinates with group coverage through a smaller employer, COBRA, being on inactive duty with TRICARE, or Medicaid. Usually, secondary insurance will only pay if the primary insurance pays its portion first.

Medicare Primary vs. Secondary Insurance with Small Employers

If your employer has fewer than 20 employees, Medicare will be your primary coverage, and your employer coverage will be your secondary coverage.

Additionally, the employer coverage is not creditable for Medicare Part B. Therefore, you will incur the late enrollment penalty if you wait. This also applies to a spouse on your group plan and is a reason why enrolling in Medicare as soon as possible is crucial.

Also, consider how much you currently pay for employer coverage. Most of the time, Medicare costs a lot less in monthly premiums. Compare both options side-by-side to see if making Medicare your primary coverage will save you money.

Who Pays First Medicare vs. COBRA

There are scenarios when you have Medicare and COBRA at the same time. Most of the time, Medicare will be primary, and COBRA will be secondary. The exception to this is if your group coverage has special rules that determine the primary payer.

It’s not common for COBRA to be the better option for someone Medicare-eligible. This is because COBRA is more expensive than Medicare. Once you enroll in Medicare, you can drop your COBRA coverage.

Another key fact is that COBRA is not creditable coverage. If you’re eligible for Medicare and do enroll, you’ll incur late enrollment penalties, as COBRA is not considered as good as Medicare. You’ll need to enroll in Medicare within the first eight months you have COBRA, even if your COBRA coverage is active longer than eight months.

Medicare and Retiree Coverage

When your group employer insurance continues to provide coverage after you retiree, you’re receiving retiree coverage. In this scenario, Medicare is primary, and your retiree converge is secondary.

Often, retiree coverage will include prescription drug coverage. If this is the case for you, you probably won’t need to enroll in a Medicare Part D prescription drug plan.

Under 65 and Disabled with Employer Group Coverage

Suppose you’re under 65, eligible for Medicare due to a disability, and have group employer coverage through a small or medium-sized employer with fewer than 100 employees. In this case, Medicare will be your primary payer, while your employer coverage is secondary.
TRICARE for Life and Medicare

When military retirees and their spouses are eligible for Medicare, they automatically qualify for TRICARE for Life (TFL). Medicare is the primary payer for any care you receive at a non-military facility. Thus, it is important for veterans to enroll in both Medicare Part A and Part B when they become eligible.

However, TFL includes good drug coverage meaning you won’t need to enroll in Medicare Part D. Some veterans with TRICARE for Life also enroll in a Medicare Advantage plan to receive additional benefits.

These extra benefits can include dental and vision coverage. In addition, TRICARE for Life will help cover some of the out-of-pocket costs that come with Medicare Advantage plans.

Medicare and Retiree Coverage

When your group employer insurance continues to provide coverage after you retiree, you’re receiving retiree coverage. In this scenario, Medicare is primary, and your retiree converge is secondary.

Often, retiree coverage will include prescription drug coverage. If this is the case for you, you probably won’t need to enroll in a Medicare Part D prescription drug plan.

Under 65 and Disabled with Employer Group Coverage

If you’re under 65, eligible for Medicare due to a disability, and have group employer coverage through a small or medium-sized employer with fewer than 100 employees, Medicare will be your primary payer, while your employer coverage is secondary.

TRICARE for Life and Medicare

When military retirees and their spouses are eligible for Medicare, they automatically qualify for TRICARE for Life (TFL). Medicare is the primary payer for any care you receive at a non-military facility. Thus, it is important for veterans to enroll in both Medicare Part A and Part B when they become eligible.

However, TFL includes good drug coverage meaning you won’t need to enroll in Medicare Part D. Some veterans with TRICARE for Life also enroll in a Medicare Advantage plan to receive additional benefits.

These extra benefits can include dental and vision coverage. In addition, TRICARE for Life will help cover some of the out-of-pocket costs that come with Medicare Advantage plans.

Is Medicare Primary or Secondary to Medicaid?

Medicaid is a state-run federal assistance program helping low-income Americans. When you become eligible for Medicare and are also eligible for Medicaid, you’re dual-eligible. For those who are dual-eligible, Medicare is the primary payer. Medicaid will not pay until Medicare pays first.

If you’re dual-eligible and need assistance covering the costs of Medicare Part B and Part D, you could qualify for a Medicare Savings Program to assist you with these costs. Always make sure your provider accepts both Medicare and Medicare before seeking care.

Can You Have Medicare and Private Insurance?

You can have both private insurance and Medicare. As we mention, most of the time, you can expect Medicare to act as the primary payer. Thus, your other form of coverage will fall into a secondary payer status.

Does Medicare Secondary Cover Primary Deductible?

No, Medicare acting as a secondary payer can’t cover the deductible of your primary insurer because to receive coverage, you’ll have to pay your deductible first.

For example, secondary insurance will pick up some or all costs after your primary insurance provider pays. However, to receive coverage from your primary insurer, you must reach your deductible first.

Is Medicare Advantage Primary or Secondary?

When you enroll in a Medicare Advantage plan, the private insurance carrier pays for your medical care instead of Medicare. Therefore, Medicare is no longer responsible for paying your claims. Your Medicare Advantage plan is your primary and only coverage.

Is Marketplace Coverage Primary or Secondary to Medicare?

Marketplace coverage and Medicare do not work together. Once you’re eligible for Medicare, you will lose any subsidies through the Marketplace.

The one exception is if you’re not eligible for premium-free Medicare Part A. Additionally, once you’re on Medicare, you cannot enroll in a Marketplace plan.

Is Veterans Affairs (VA) Benefits Primary or Secondary to Medicare?

Medicare and Veterans Affairs (VA) benefits don’t work together; both are primary. When you go to a veterans’ facility, your VA benefits are your primary and only coverage. On the other hand, at a civilian facility, Medicare is your primary and only coverage.

By having both Veterans’ and Medicare benefits, you get access to all civilian and non-civilian doctors and hospitals.

Is a Medicare Supplement Plan Primary or Secondary?

Medicare Supplement plans are secondary payers to Medicare. The facility where you receive care will bill Medicare first. Then, they will bill your Medicare Supplement plan.

Does Medicare Send Claims to Your Medicare Supplement Insurance?

When you have a Medicare Supplement plan, Medicare will receive all claims first. Then, Medicare will bill the remainder to your Medicare Supplement carrier. Once both of your coverages have paid their portion, the remainder of the bill will be your responsibility.

What Is the Medicare Secondary Payer Act?

Congress passed the Medicare Secondary Payer Act to ensure that Medicare funds are not being used to pay for services that other health insurance coverage would normally pay for as primary.

Do You Need Secondary Insurance with Medicare?

Whether you will require secondary insurance with Medicare depends on your health needs. Since Medicare doesn’t cover 100% of your healthcare costs, obtaining a form of secondary coverage, such as Medigap, helps cover out-of-pocket costs and can reduce your financial obligation.

How Do Primary and Secondary Insurance Work with Medicare Part D?

When you have Medicare Part D prescription drug coverage and another insurance plan, such as an employer-sponsored group health plan, one plan typically serves as the primary coverage and the other as secondary.

If you have Medicare Part D and another prescription drug insurance plan, your Medicare Part D coverage will generally be the primary payer for your prescription drug expenses. Your other insurance plan, such as an employer-sponsored group health plan, would then serve as the secondary payer.

In this scenario, your Medicare Part D plan pays first for your covered prescription drug expenses up to the limits of your plan’s coverage. Your other insurance plan would then pay some or all of the remaining costs up to the limits of that plan’s coverage.

It’s important to note that if you have other insurance coverage in addition to Medicare Part D, such as an employer-sponsored group health plan, you are required to inform both plans of your coverage. This is to ensure that both plans work together correctly to pay for your healthcare expenses and avoid any delays or denials of coverage.

How To Know if Medicare Is Primary or Secondary

Depending on the situation at hand, Medicare may be your primary or secondary converge. However, it is important to know in which order your health care is responsible for paying.

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