When Does Medicare Pay First?

• by Christian Worstell
• January 12, 2024
• Reviewed by John Krahnert

When you have other types of insurance in addition to Medicare, who pays first?

Medicare is the largest health insurance provider in the U.S. Many Medicare beneficiaries may also have other types of health insurance, such as retiree health insurance benefits, military insurance, COBRA or other types of coverage in addition to their Medicare benefits.

Read below to find out when Medicare pays first, when it serves as the secondary payer and how it works with military coverage and workplace health insurance.

Medicare pays first when it serves as your primary payer

If you have Medicare as well as another type of insurance, your coverage is provided through a coordination of benefits. In some situations, Medicare will serve as your primary payer, which means Medicare pays first. Your other insurance coverage will then serve as your secondary payer.

In the following situations, Medicare acts as your primary payer:

1. You are “dual-eligible” (entitled to both Medicare and Medicaid). Medicaid becomes the secondary payer after Medicare pays first.
   
   
2. You are age 65 or older and are covered by a group health plan because you or your spouse is still working and the employer has fewer than 20 employees. The group health plan in this situation serves as the secondary payer.
   
   
3. You are retired and entitled to Medicare, but you still receive health insurance from your former employer. The retiree coverage is the secondary payer if you enroll in Medicare, which will pay first for qualified services.
   
   
4. You are disabled and have workplace coverage provided through an employer with fewer than 100 employees. The group health plan is your secondary payer after Medicare pays first for your health care costs.
   
   
5. You have End-Stage Renal Disease (ESRD), are covered by a group health plan and have been entitled to Medicare for at least 30 months. The group health plan pays second, after Medicare.
   
   
6. You have ESRD and COBRA insurance and have been eligible for Medicare for at least 30 months. COBRA is the secondary payer in this situation, and Medicare pays first for qualified services.
   
   
7. You are 65 or over – or you are under 65 and have a disability other than ESRD – and are covered by either COBRA insurance or a retiree group health plan. COBRA or the retiree health plan (whichever one you have) is the secondary payer.  

Your other insurance pays first when Medicare is the secondary payer

Medicare serves as the secondary payer in the following situations:

1. You are 65 or older and are covered by a group health plan because you or your spouse is still working and the employer has 20 or more employees. The group health plan is the primary payer, and Medicare pays second.
   
   
2. You are disabled and covered by an employer-provided group health plan, and the employer has 100 or more employees. The group health plan is the primary payer.
   
   
3. You have ESRD, you are enrolled in a group health plan and you have been eligible for Medicare for 30 months or fewer. The group health plan pays first for qualified services, and Medicare is the secondary payer.
   
   
4. You have ESRD and COBRA insurance and have been eligible for Medicare for 30 months or fewer. COBRA pays first in this situation.

How does Medicare work with military insurance benefits?

If you are entitled to both Medicare and Veteran’s Administration benefits, Medicare pays for any Medicare-covered services or items. Your Veteran’s benefits will pay for any VA-authorized services or items that are not covered by Medicare.

Medicare and the VA generally do not work together to pay for the same service or item. You may use both types of insurance for your health care, but they will operate separately from each other.

TRICARE does work with Medicare. Active-duty military personnel who are enrolled in Medicare may use TRICARE as a primary payer, and then Medicare pays second as a secondary payer.

For inactive members of the military who are enrolled in Medicare, Medicare acts as the primary payer and TRICARE pays second, provided that the services or items are received in a military hospital or other approved federal provider.

Does Medicare pay first with workers’ compensation or liability insurance?

If you have been injured in an accident where liability insurance is involved and you are also entitled to Medicare benefits, the liability insurance provider pays first, and Medicare pays as the secondary payer.

If you are covered under workers’ compensation due to a job-related injury or illness and are entitled to Medicare benefits, the workers’ compensation insurance provider will be the primary payer. There typically is no secondary payer in such cases, but Medicare may make a payment in certain situations.

Your private Medicare insurance coverage choices

Part A and Part B of Medicare are provided by the government, and your eligibility is typically based on your age. But there are three types of Medicare coverage that are sold by private insurance companies.

These private Medicare insurance options include:

• Medicare Part C plans, or Medicare Advantage plans, offer all the same basic benefits as Medicare Part A and B. A Medicare Advantage plan replaces your Original Medicare coverage. A Medicare Advantage plan may also offer benefits not found in Original Medicare. 
  
  While you must remain enrolled in Medicare Part A and Part B (and pay the associated premiums), your Medicare Advantage plan serves as your Medicare coverage.
  
  
• Medicare Part D, which provides coverage for prescription drugs, is another type of private Medicare insurance.
  
  These plans can be used in conjunction with Medicare Part A and Part B (or with a Medicare Advantage plan that doesn’t include prescription drug coverage) to provide coverage exclusively for certain prescription drugs.
  
  You can compare Part D plans available where you live and enroll in a Medicare prescription drug plan online when you visit MyRxPlans.com.
  
  
• Medicare Supplement Insurance, or Medigap, can help cover some of the out-of-pocket costs associated with Part A and Part B of Medicare. These costs can include certain Medicare deductibles and coinsurance or copayments. You can use a Medicare Supplement plan alongside your Original Medicare coverage, but you can't have a Medicare Supplement plan and a Medicare Advantage plan at the same time.

Because each of these types of Medicare coverage is sold by private insurance companies, the cost and availability of plans may vary from one location or provider to the next.

Read additional Medicare cost guides to learn more about Medicare costs and how they will affect you.

Explore your private Medicare Advantage coverage options

Learn more about when Medicare pays first for your care and compare Medicare plan options that may be available where you live. To get started, call to speak with a licensed insurance agent or compare plans for free online.

Or call 1-800-557-6059 1-800-557-6059 TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!

Learn more about Medicare enrollment

• How much does Medicare cost by state?
• Does Medicare cost change by income level?
• How do I cancel Medicare?
• What is Medicare Easy Pay?
• How do I enroll in a Medicare Advantage plan?
• What is a Special Enrollment Period?
• What is a Medicare Special Needs Plan?
• What is the average cost of Medicare?
• What is a 5-star Medicare Advantage plan?

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.

 

 

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