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Is Medicare Primary or Secondary?


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 what form of coverage is primary and which is secondary.

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Medicare, primary or secondary, still offers excellent benefits to seniors, but the difference involves which coverage pays for healthcare first. Your primary coverage will pay first, and your secondary coverage will pay after. 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?

Medicare is your primary coverage when you have group insurance. However, there are many examples of Medicare as secondary insurance. Here are examples of scenarios in which seniors may find themselves.

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Group Coverage Through Larger Employer

Many people on Medicare have group insurance through their company or spouse’s employer. In this case, Medicare is secondary coverage when the employer has more than 20 employees.

Seniors choosing to delay their Medicare Part B enrollment because their group coverage is cheaper should note that in many cases, Medicare will provide better coverage and cost less when it acts as their primary coverage.

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.

End-Stage Renal Disease (ESRD)

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Medicare will be your secondary coverage if you’re diagnosed with ESRD, have group employer coverage, and have been Medicare-eligible for less than 30 months.

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. Below are some of the more prevalent examples.

TRICARE

TRICARE pays first for Medicare-approved services at a civilian facility, but if you’re on active duty, Medicare will pay second. Medicare doesn’t cover treatment provided by a military hospital or federal health care provider.

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.

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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.

Medicare Primary, COBRA As Secondary

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There are scenarios when you’ll 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 not 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.

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.

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TRICARE for Life

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.

End-Stage Renal Disease (ESRD)

Seniors diagnosed with ESRD keep their current employer coverage as primary coverage for the first 30 months. After these first 30 months, your primary coverage automatically switches over to Medicare, like it would with COBRA or retiree insurance.

If you receive Medicare due to ESRD and have a successful kidney transplant, your Medicare eligibility will end after 36 months. If you’re eligible for Medicare due to age or disability, then you will remain on Medicare even after your kidney transplant.

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.

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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 Private Insurance and Medicare?

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, your much 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.

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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 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.

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?

Medicare Part D coordinates with other prescription drug plans. Any other prescription coverage you have will determine which coverage between the two is primary and secondary.

How To Know if Medicare Is Primary or Secondary

Are you wondering whether Medicare is primary or secondary to your current healthcare coverage? Are you frustrated being alone trying to figure out what secondary supplemental plans are available to you?

Give us a call at the number above. Our agents can answer your questions and help you identify which coverage is best for your healthcare needs. If you prefer to compare options in your area online, fill out an online rate form now.

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Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

24 thoughts on “Is Medicare Primary or Secondary?

  1. Hi Samantha. That is a great question! This is because Medicare Advantage replaces your Original Medicare benefits. Medicare is no longer responsible for your medical costs, the Advantage plan is. Medicare pays the Advantage carrier to take on your risk. That’s how the carriers are able to offer zero-premium plans.

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