Who pays first?

There seems to be a lot of confusion about who pays first if a person also has other healthcare coverage apart from Medicare. This article tries to explain who the primary and secondary payers are for common situations in such circumstances.

Who pays first?

If you have Medicare along with other healthcare coverage, it can be confusing to understand who pays first and for what. The table below will help you in navigating through these choppy waters. Note that these are general guidelines. Exceptions may apply.

It is advisable to confirm the order of payment with your ‘other health coverage’ provider and correspondingly inform your doctor, hospital and other care providers of the same so that they send the bills to the correct payer and avoid delays.

If you are covered by a Group Health Plan

Primary Payer

Secondary Payer

Based on you or your spouse/family member working at a firm which has 20 or more employees

 

Group health plan

Medicare

Based on you or your spouse/family member working at a firm which has less than 20 employees

 

Medicare

Group health plan

You are disabled and coverage is based on you or your family member working at a firm with 100 or more employees

 

Group health plan

Medicare

You are disabled and coverage is based on you or your family member working at a firm with less than 100 employees

 

Medicare

 

Group health plan

You have End-Stage Renal Disease (ESRD) and group health plan coverage (including a retirement plan)

  • During first 30 months of eligibility or entitlement to Medicare

 

  • After 30 months

 

 

 

 

Group health plan

 

 

Medicare

 

 

 

 

Medicare

 

 

Group health plan

 

 

If you are covered by COBRA

Primary Payer

Secondary Payer

You are 65 or over or disabled, and are also covered by COBRA

 

Medicare

COBRA

You have ESRD and are covered under COBRA

  • First 30 months of eligibility or entitlement to Medicare

 

  • After 30 months

 

 

COBRA

 

 

Medicare

 

 

Medicare

 

 

COBRA

 

 

If you are covered by Medicaid

Primary Payer

Secondary Payer

You are enrolled in a Medicaid program

  • Medicare
  • Employer health plans
  • Medicare Supplement

 

Medicaid

 

If you are covered by Federal Employee Health Benefits

Primary Payer

Secondary Payer

Active Federal Employee

 

FEHB

Medicare

 

If you are covered by TRICARE

Primary Payer

Secondary Payer

Active-duty military personnel

 

Inactive-duty military personnel

TRICARE

 

Medicare pays for Medicare-covered services

 

TRICARE pays for services provided by a military hospital or other federal providers

 

N/A

 

If you have coverage not mentioned above

Primary Payer

Secondary Payer

If you are in an accident where no-fault or liability insurance is involved

 

Insurance provider

 

Medicare

If you are getting workers’ compensation because of a job-related illness or injury

Workers’ compensation for services or items related to workers’ compensation claim

 

Does not apply, but Medicare may make a conditional payment

If you are affected by black lung disease and are covered under the Federal Black Lung Benefits Program

Federal Black Lung Benefits Program for services related to black lung

 

Medicare

 

                                                                                                                                                  

Click here to learn more about Medicare, its various Parts, different enrollment periods and your costs. 

We have also created videos to help you better understand various topics related to Medicare. Select and watch a video explaining the topic of your interest in a simple and intuitive manner.

Remember that you cannot choose just any combination of Parts and Plans. Let Lighted Road Insurance guide you step-by-step through the Medicare ecosystem and help you in selecting the right plan(s) for your needs.