Paul Sanchez
Medicare is the federal health insurance program for people aged 65 and over in the US. If you have other insurance, such as from your employer, retiree coverage, or Medicaid, and you're wondering how this works with Medicare, you're in the right place. Each type of coverage is called a payer, and one will pay first (the primary payer) and the other second (the secondary payer). If you have other insurance, who pays first depends on factors such as whether you're still working, the type of insurance you have, and whether you have a special situation, like End-Stage Renal Disease (ESRD). If you have Medicare and other health insurance, it's important to tell your doctor and other healthcare providers so they can send your bills to the correct payer and avoid delays.
| Characteristics | Values |
|---|---|
| Medicare eligibility | People aged 65 and over |
| People under 65 with a disability, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig’s Disease) | |
| Initial Enrollment Period | Begins 3 months before the month you turn 65 and ends 3 months after |
| You may have to pay a penalty if you miss your Initial Enrollment Period | |
| Medicare Parts | Part A: Hospital Insurance |
| Part B: Medical Insurance | |
| Part C (Medicare Advantage Plans): Private insurance option that covers hospital and medical costs | |
| Part D: Prescription medications | |
| Medicare and other insurance | 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 the "secondary payer" doesn’t cover the remaining balance, you may be responsible for the remaining costs | |
| Medicare Supplement Insurance (Medigap) | Extra insurance you can buy from a private company that helps pay your share of costs in Original Medicare |
| Generally, you need Part A and Part B to buy a Medigap policy | |
| Some Medigap policies offer coverage when you travel outside the US |
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What You'll Learn
Understanding primary and secondary payers
When you have Medicare and another form of health insurance, one will be the "primary payer" and the other will be the "secondary payer". The primary payer is the insurer that has the primary responsibility for paying a claim and will pay up to the limits of its coverage. The secondary payer then covers the remaining costs, such as coinsurances or copayments.
The primary payer pays the amount agreed upon by your plan first. If your primary payer is Medicare, Medicare Part B would pay 80% of the cost. Typically, you are responsible for the remaining 20%. If you have a secondary payer, they will pay the remaining 20% instead. However, in some cases, the secondary payer might not pay all the remaining costs, in which case you will receive a bill for the leftover amount.
If you have insurance through your job, Medicare will usually be the secondary payer. However, if you work for a small company with fewer than 20 employees, Medicare will be the primary payer. If you are over 65 and have retiree coverage, Medicare will be the primary payer and your retiree coverage will be the secondary payer. If you are under 65 and have retiree coverage, your insurance will be the primary payer and Medicare will be the secondary payer.
There are some other situations in which Medicare will be the secondary payer. For example, if you have End-Stage Renal Disease (ESRD) and are covered by a Group Health Plan (GHP), the GHP will be the primary payer and Medicare will be the secondary payer. If you are disabled and covered by a GHP through your own or a family member's employment, and the employer has over 100 employees, the GHP will be the primary payer and Medicare will be the secondary payer.
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Medicare with other insurance
Medicare is the federal health insurance program for people aged 65 and over. If you are under 65, you may be eligible for Medicare if you have a disability, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig's Disease).
Original Medicare includes two parts: Part A (Hospital Insurance) and Part B (Medical Insurance). After meeting your deductible, you pay your share of the costs for services and supplies as you get them. There is no limit on what you will pay out-of-pocket in a year unless you have other coverage, such as Medigap, Medicaid, employer, retiree, or union coverage.
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 and then sends the rest of the balance to the "secondary payer." If the "secondary payer" does not cover the remaining balance, you may be responsible for the remaining costs. The order of payment is called "coordination of benefits."
Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private company to help pay your share of costs in Original Medicare. Generally, you need Part A and Part B to buy a Medigap policy, and some Medigap policies offer coverage when you travel outside the US.
If you have other insurance, who pays first depends on several factors, such as whether you are still working, the type of insurance you have, and if you have a special situation like End-Stage Renal Disease (ESRD).
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Medicare Supplement Insurance (Medigap)
Medicare Supplement Insurance, also known as Medigap, is extra insurance that you can purchase from a private health insurance company. It helps cover the out-of-pocket costs associated with Original Medicare (Part A and Part B). These costs include deductibles, copays, and coinsurance. Medigap policies are available in all 50 states and Washington, D.C., with varying premiums and enrolment eligibility.
To be eligible for a Medigap policy, you generally need to be enrolled in Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance). Medigap plans are designed to fill the coverage gaps in Original Medicare, which does not cover all costs for approved health care services and supplies. With Medigap, you can receive coverage for emergency services during foreign travel, which is not typically covered by Original Medicare.
It is important to note that Medigap policies do not cover certain benefits, such as long-term care, vision, dental, hearing aids, private-duty nursing, or prescription drugs. Additionally, if you are under 65, you may face restrictions or higher costs when purchasing a Medigap policy.
Medigap plans are standardized, and in most states, they are named by letters, such as Plan G or Plan K. The benefits offered by each lettered plan are consistent across insurance companies, with the price being the only differentiating factor between companies.
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Medicare Advantage Plans
If you have Medicare and other health insurance, one will be the "primary payer" and the other the "secondary payer". The primary payer pays up to its coverage limits and then sends the remaining balance to the secondary payer. If the secondary payer doesn’t cover the remaining balance, you may be responsible for the remaining costs. The order of payment is called "coordination of benefits".
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Medicare Part A and Part B
Medicare is federal health insurance for anyone aged 65 or older and some people under 65 with certain disabilities or conditions. Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
Medicare Part A covers inpatient hospital care, doctors' services and tests, and preventive services. Most people get Part A for free, but some have to pay a premium for this coverage. To be eligible for premium-free Part A, an individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child. To receive premium-free Part A, the worker must have a specified number of quarters of coverage (QCs) and file an application for Social Security or Railroad Retirement Board (RRB) benefits. The exact number of QCs required depends on whether the person is filing for Part A on the basis of age, disability, or End Stage Renal Disease (ESRD). QCs are earned through payment of payroll taxes under the Federal Insurance Contributions Act (FICA) during the person's working years.
Medicare Part B helps cover two types of services: medically necessary services and preventive services. Medically necessary services are services or supplies that meet accepted standards of medical practice to diagnose or treat a medical condition. Preventive services are healthcare to prevent illness (like the flu) or detect it at an early stage when treatment is likely to work best. You pay nothing for most preventive services if you get them from a healthcare provider who accepts the assignment. If you have Part B and Medicare Supplement Insurance (Medigap) that pays your Part B coinsurance, your Medigap plan should cover the $35 (or less) cost for insulin.
If you have other insurance, such as from your job, Medicare and your other insurance will each be called a "payer." One will pay first (the "primary payer") and the other second (the "secondary payer"). If the "secondary payer" doesn't cover the remaining balance, you may be responsible for the rest of the costs.
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Frequently asked questions
Medicare is the federal health insurance program for people aged 65 and over. It also covers those under 65 with a qualifying disability, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig's Disease).
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 and 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.
Whether an insurance is considered "primary" or "secondary" depends on several factors, including if you're still working, the type of insurance you have, and if you have a special situation like End-Stage Renal Disease (ESRD).
Yes, there are a few situations where you can choose a Marketplace plan over Medicare. For example, if you're paying a premium for Part A (Hospital Insurance), you can drop Part A and Part B and get a Marketplace plan.
