If you have Medicare and other group health insurance through your employer. each type of coverage is called a “payer.” When there’s more than one payer, Medicare’s coordination of benefit rules decide who pays first. The “primary payer” pays what it owes on your bills first, and then sends the rest to the “secondary payer” to pay.
What is a primary versus a secondary payer?
- The insurance that pays first (primary payer) pays up to the limits of its coverage.
- The one that pays second (secondary payer) only pays if there are costs the primary insurer didn’t cover.
- The secondary payer (which may be Medicare) may not pay all the remaining costs.
- If you are enrolled in a group health plan through your employer and your employer has 20 or more employees, you’ll likely need to enroll in Medicare Part B before your group health plan will pay.
If your group health plan doesn’t pay your claim in a reasonable amount of time (usually within 120 days), your provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should’ve made.
How do I know if my group health plan is primary or secondary?
When it comes to whether or not your group health plan is primary, if your employer has 20 or more employees, then the group health plan pays first, and Medicare pays second. If your 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 your group health plan doesn’t cover.
If your 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 your group health plan pays second. In this instance, you will need to enroll in Medicare Part B.
It is important that you understand who is the primary and secondary payer for your health claims and review your Medicare and your group health plan Explanation of Benefits (EOBs) for accuracy. If you are unsure, check with your health plan first and ask if it will pay first or second.
For more information, please visit http://www.medicare.gov.