What Insurances Pay Primary to Medicare?
Question:
I have Medicare Part A and Part B, but I also have another
health insurance policy from my current job. How does Medicare work with my other coverage, and do I need to tell my doctor if I have more than one type of insurance?
Answer:
Your current employee insurance may pay primary to Medicare. Whether it will pay primary or not depends on how you are eligible
for Medicare and how many people work at the company that provides the insurance.
Insurance from your or your spouse’s current employment pays primary to Medicare if you (a) are eligible for Medicare because you are 65 or older and the company has 20 or more employees, or (b) are eligible for Medicare because you have received Social Security Disability Insurance (SSDI) payments for more than 24 months and the company has 100 or more
employees.
Note that if you have Medicare because you have received SSDI payments for more than 24 months, the insurance based on current employment can also be from a family member’s current work. This is an important distinction, because if you are eligible for Medicare due to age, the current employment-based coverage can only be from your or your spouse’s current work.
Insurance from current employment can be from a private company (such as a bank or small
business), a union, or a Small Business Health Options Program (SHOP) plan, which is a type of current employee coverage available through the Health Insurance Marketplace. If you or your spouse are currently working for the federal government and covered by Federal Employee Health Benefits (FEHB), the rules are the same. FEHB always pays primary to Medicare because the federal government has more than 100 employees.
Insurance from your or your spouse’s
current employment pays secondary to Medicare if you (a) are eligible for Medicare because you are 65 or older and the company has fewer than 20 employees, or (b) are eligible for Medicare because you have received SSDI payments for more than 24 months and the company has fewer than 100 employees (note that if you have Medicare due to disability, the insurance based on current employment can also be from a family member’s current
work).
Homework:
You should inform your doctor about any different insurance that you have in order to avoid any billing or coverage problems. You can do this by showing your different health insurance cards at the front desk to ensure that your file is up to date. It is important to let
your providers know which insurance is primary and which is secondary so that there are no problems. If your secondary insurance is billed first, for example, you may experience coverage denials or other difficulties accessing services because your secondary insurance will not pay until the primary insurance does.
