Haris Ashley
Medicare Advantage, also known as Medicare Part C, is one of the two main ways to get your Medicare coverage. When you have both Medicare and employer coverage, Medicare Advantage can coordinate with group insurance, but the coordination depends on which insurance is considered primary and secondary. The size of the employer also determines how the benefits will coordinate. If you have non-tribal group health coverage through an employer with 20 or more employees, the non-tribal group health plan pays first, and Medicare pays second. If you have coverage through an employer with fewer than 20 employees, Medicare pays first, and the non-tribal group health plan pays second.
| Characteristics | Values |
|---|---|
| Medicare Advantage Coordination with Group Insurance | Medicare Advantage coordinates with group insurance, but the primary and secondary payers must be defined. |
| Primary Payer | The primary payer is typically the group health plan for employers with 20 or more employees. Medicare is the primary payer for smaller companies with fewer than 20 employees. |
| Secondary Payer | If Medicare is the secondary payer, it covers 80% of outpatient costs. |
| Order of Payment | The primary payer pays up to its limits, then sends the remaining balance to the secondary payer. If the secondary payer doesn't cover the remaining balance, the individual may be responsible for the remaining costs. |
| Medicare Advantage and Drug Coverage | Medicare Advantage Plans typically include Part D drug coverage. Individuals cannot usually join a separate Medicare drug plan with Medicare Advantage. |
| Medicare Advantage and Worker's Compensation | Medicare Advantage must be repaid from the Worker's Compensation Medicare Set-aside Arrangement if it pays for claims related to worker's compensation. |
| Medicare Advantage and Spousal Coverage | Medicare Advantage can provide coverage for spouses, potentially saving costs compared to employer group plans. |
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What You'll Learn
Medicare Advantage and primary/secondary insurance
Medicare Advantage is one of the two main ways to get your Medicare coverage. The other is Original Medicare. If you have Medicare and other health insurance (like from a group health plan, retiree coverage, or Medicaid), each type of coverage is called a "payer". The "primary payer" pays up to the limits of its coverage, then sends the rest of the balance to the "secondary payer". The insurance that pays first (primary payer) pays up to the limits of its coverage. The insurance that pays second (secondary payer) only pays if there are costs the primary insurance didn't cover.
If you have non-tribal group health plan coverage through an employer with 20 or more employees, the non-tribal group health plan pays first, and Medicare pays second. If your employer has fewer than 20 employees, Medicare pays first, and the non-tribal group health plan pays second. If you have health insurance through a tribal health plan, Medicare pays first and the tribal health plan pays second. If you get drugs through an Indian health facility, you will continue to get them at no cost, and your coverage won't be interrupted.
If the insurance company doesn't pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should have made. If you're enrolled in a Medicare Advantage or a Medicare drug plan, the plan will contact you to investigate claims and request repayment. You're responsible for cooperating with the Benefits Coordination & Recovery Center, Medicare Advantage, or Medicare drug plan’s efforts to verify if claims are related to your workers’ compensation settlement and repay Medicare for those claims.
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Medicare Advantage and employer coverage
Medicare Advantage is one of the two main ways to get your Medicare coverage. The other is Original Medicare. Medicare Advantage Plans typically include Part D coverage, which is prescription drug coverage. Medicare Advantage and employer coverage can work together, but it depends on the size of the employer. If you have non-tribal group health plan coverage through an employer with 20 or more employees, the non-tribal group health plan pays first, and Medicare pays second. If your employer has fewer than 20 employees, Medicare pays first, and the non-tribal group health plan pays second.
If you are covered by a group health insurance plan through your employer or your spouse's employer, you may want to consider enrolling in Medicare. However, there are a number of considerations to take into account. For example, if you enrol in any part of Medicare, you will be prohibited from contributing to a Health Savings Account (HSA). Therefore, you should not enrol in Part B unless you have End-Stage Kidney Failure. However, if you are already taking Social Security benefits, you will be automatically enrolled in Medicare and will have to decline Part B manually if you do not want it while you are still working.
If you are enrolled in a Medicare Advantage or a Medicare drug plan, the plan will contact you to investigate claims and request repayment. You are responsible for cooperating with the Benefits Coordination & Recovery Center, Medicare Advantage, or Medicare drug plan's efforts to verify if claims are related to your workers' compensation settlement and repay Medicare for those claims.
If you are unsure about who pays first or if your coverage changes, you can call the Benefits Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627).
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Medicare Advantage and workers' compensation
Medicare Advantage is one of the two main ways to get your Medicare coverage. The other is Original Medicare. When you have coverage through both Medicare and workers' compensation, it's important to understand how your benefits coordinate.
Workers' compensation is a state-administered program that pays for healthcare and other claims related to job-related injuries or illnesses. If you have both Medicare and workers' compensation, workers' compensation is the primary payer and Medicare is the secondary payer. This means that any doctors or other healthcare providers you see due to your work-related illness or injury must bill workers' compensation first. If the workers' compensation insurer does not pay for your medical bills within 120 days, Medicare may make a conditional payment, which must be repaid from your workers' compensation settlement, award, or other payment.
If you have a Medicare-approved Workers' Compensation Medicare Set-aside Arrangement (WCMSA) amount, you are responsible for cooperating with the Benefits Coordination & Recovery Center (BCRC) to verify if claims are related to your workers' compensation settlement and repay Medicare for those claims. When contacting the BCRC, make sure you have the following information: the date of your injury/accident, a description of the injury or illness, the type of claim (worker’s compensation, no-fault insurance, etc.), and the name and address of the workers' compensation insurer.
If you plan to settle your workers' compensation claim, it is important to set aside funds in a special account called a Workers' Compensation Medicare Set-Aside Agreement (WCMSA). This account can be used to pay future medical bills related to your injury and to repay Medicare for any of its conditional payments. You will need a lawyer's assistance to settle your claim and create this set-aside agreement account. Before reaching a workers' compensation settlement, your lawyer should typically contact the Medicare coordination of benefits contractor to get Medicare approval of the amount you plan to put in the account.
It is important to note that Medicare will only cover costs under certain circumstances while your workers' compensation claim is being reviewed. Once your claim is approved and you receive your settlement, there are certain rules Medicare has in place regarding covering costs related to your work injury.
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Medicare Advantage and spousal insurance
Medicare Advantage, also known as Part C, is a type of plan offered by a private insurance company that provides you with all your Medicare Part A and Part B services. If you are covered by your spouse's employer plan and eligible for Medicare, you have several options.
Firstly, you can choose to delay enrolling in Medicare until you lose your spouse's employer coverage. Alternatively, you can choose to only enroll in Part A, as it usually has no premium. However, you will need to ensure you have creditable coverage to avoid paying late premium penalties for Part B and/or Part D.
If you are eligible for Medicare based on your spouse's work history, you can enroll in Medicare Part A for free, even if you are widowed or divorced. If you are divorced, you must have been married for at least 10 years, and your ex-spouse must be at least 62 years old. If widowed, you must have been married for at least one year. You can also enroll in Medicare Part B and Part D prescription drug coverage.
If you are enrolled in Medicare Advantage, your spouse will have their own premium, deductible, and copays, even if you have the same plan. You may be charged a separate premium by the insurance company in addition to your Part B premium and may be eligible for additional benefits, including prescription drugs.
If you have Medicare and other health insurance, such as a group health plan, each type of coverage is called a "payer." The "primary payer" pays up to the limits of its coverage, then sends the rest of the balance to the "secondary payer." If the "secondary payer" doesn't cover the remaining balance, you may be responsible for the remaining costs. In most cases, if you have a non-tribal group health plan with fewer than 20 employees, Medicare pays first, and the group health plan pays second.
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Medicare Advantage and group health insurance for large employers
If you have Medicare and other health insurance, such as a group health plan, each type of coverage is called a "payer". The "primary payer" pays up to the limits of its coverage and then sends the remaining balance to the "secondary payer". If the "secondary payer" does not cover the remaining balance, you may be responsible for the remaining costs. This order of payment is called "coordination of benefits".
If you have a non-tribal group health plan through an employer with 20 or more employees, the non-tribal group health plan pays first, and Medicare pays second. If your employer has fewer than 20 employees, Medicare pays first, and the non-tribal group health plan pays second.
Medicare Advantage (Part C) plans are offered by private companies as an alternative to Original Medicare for health and drug coverage. In most cases, you can only use doctors within the plan's network. Medicare Advantage Plans include Part D coverage, and most plans have a monthly premium that you pay in addition to your Part B premium.
If you are covered by a group health insurance plan through your employer or your spouse's employer, you should consider your options before enrolling in Medicare. For instance, if you are eligible for Medicare based on kidney failure and are covered by a group health plan, Medicare will kick in after the first 30 months of dialysis treatment.
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Frequently asked questions
If you have Medicare and other health insurance, each type of coverage is called a "payer". The "primary payer" pays up to the limits of its coverage, then sends the rest of the balance to the "secondary payer". If your group health plan is the secondary payer, you may need to sign up for Medicare Part B before they pay. This order of payment is called "coordination of benefits".
The size of your employer will determine whether Medicare or your group health insurance is the primary payer. If you work for a company with 20 or more employees, your group plan will be the primary payer and Medicare will be the secondary payer. If you work for a smaller company, Medicare will be the primary payer and your group insurance will be the secondary payer.
You're responsible for cooperating with the Benefits Coordination & Recovery Center and Medicare Advantage's efforts to verify if claims are related to your workers' compensation settlement and repay Medicare for those claims from your Workers' Compensation Medicare Set-aside Arrangement.
