Who pays first between Medicare and my group insurance?

BY IRENE CARD AND BETSY CHANDLER

NEWJERSEYNEWSROOM.COM

YOUR HEALTH INSURANCE

The information in this article does NOT pertain to Medicare supplements. This article is only relevant if you have Medicare PLUS insurance from a former employer or spouses' employer. You may wish to print this out, date it and save it as the information may not be relevant to you at this time but you may need this data at some date in the near future. There is no yes or no answer to the question: "Who pays first, Medicare or your group health insurance"? The answer depends on a number of factors. Most importantly, make sure your doctor and other health care providers (the hospital, for example) know in which order to submit your claims.

If you are age 65 or older and covered by a group health plan because you are working or are covered by a group health plan of a working spouse of any age, and are entitled to Medicare, and the employer has more than 20 employees, your group health plan pays first and Medicare is secondary. This is part of the Tax Equity and Fiscal Responsibility Act of 1986 (TEFRA) wherein the government decided that if an individual continues to work past their 65th birthday for a company with more than 20 employees (or if the spouse is working for such a company), group insurance is primary and Medicare is secondary. If the employer has less than 20 employees, Medicare is primary and the group health plan is secondary.

If you are retired and have an employer retiree plan and are age 65 or older, and are entitled to Medicare, Medicare is primary and your retiree coverage is secondary.

If you are disabled and covered by a large group health plan from your employer, or from a family member who is working, and are entitled to Medicare and the employer has 100 or more employees, the large group health insurance plan is primary and Medicare is secondary. If the employer has less than 100 employees, Medicare is primary and the group health insurance plan is secondary.

If you have been in an accident where no-fault or liability insurance is involved, and are entitled to Medicare, the no-fault (auto insurance) or liability insurance for accident related services is primary and Medicare is secondary.

If you are covered under workers' compensation because of a job-related illness or injury, and are entitled to Medicare, workers' compensation is primary if the claim is related to a workmen's compensation injury. Usually, Medicare does not apply. However, Medicare may make a conditional payment.

If you are a Veteran and have Veterans' benefits, and are entitled to Medicare and Veterans' benefits, Medicare will pay for Medicare-covered services. Veterans' Affairs will pay for VA authorized services. Medicare and the VA cannot pay for the same service.

If you are covered under Tricare and are entitled to both Medicare and Tricare, Medicare pays for Medicare covered services and Tricare may pay as secondary. Tricare pays for services from a military hospital or any other federal provider, as primary.

If you are 65 or over OR disabled and covered by Medicare and COBRA coverage, and are entitled to Medicare, Medicare is primary and COBRA is secondary.

If you have end stage renal disease (permanent kidney failure) and group health plan coverage (including a retirement plan), the first 30 months of eligibility or entitlement to Medicare, your group health insurance plan will be primary and Medicare will pay second. After 30 months, Medicare will be primary and your group health plan will be secondary.

If you have end stage renal disease (permanent kidney failure) and COBRA coverage, the first 30 months of eligibility or entitlement to Medicare, COBRA is primary and Medicare pays second. After 30 months, Medicare will be primary and COBRA will be secondary.

Some of the information in this article was extrapolated from the Government publication, "Medicare and other health benefits: Your guide to who pays first". You may access the entire booklet on the Internet. www.Medicare.gov.

Irene Card & Betsy Chandler are both licensed insurance professionals working at MIC Insurance Services, a health insurance services company. If you have questions relative to this column or other related topics, we invite you to call (973) 492-2828, browse our past columns on our web site at www.micinsurance.com.