When Medicare is primary insurance?

If in addition to Medicare you have other health insurance plan (such as an employer group health plan), then it is essential to know when Medicare is primary insurance. If Medicare is primary, then it pays the bills first, up to the limit of its coverage. The secondary insurance pays only after Medicare paid its share.  Alternatively, if Medicare is secondary, then it pays after the primary insurance paid.  If you do not have primary insurance, the secondary insurance will cover very little of your health expenses or nothing at all.

Read below about the most important cases that determine whether Medicare is primary insurance. For more details, review the following CMS publication Medicare and Other Health Benefits: Your Guide to Who Pays First.

If you have Medicare and do not Work

Medicare is primary insurance and pays first.

• You are covered by Medicare and Medicaid. Medicaid is secondary insurance, but only after the other coverage (such as employer group health plans) has paid.
• You are 65 or older, and have Medicare and an employer group health plan after you retire, Your secondary coverage is your Retiree Coverage
• You are 65 or over (or disabled) and covered by Medicare and COBRA coverage. Your secondary coverage is your COBRA.

If you have Medicare and still Working

If you are still working, Medicare can sometimes be primary and sometimes be secondary, depending on the situation.

Medicare is the primary insurance if:

• You 65 or older, entitled to Medicare and covered by a group health plan because you or your spouse is still working, AND the employer has less than 20 employees
• You are under 65, entitled to Medicare due to disability  and covered by a large group health plan from your work, or from a family member who is working, AND the employer has less than 100 employees

Medicare is the secondary insurance if:

• You 65 or older, entitled to Medicare and covered by a group health plan because you or your spouse is still working, AND the employer has 20 or more employees
• You are under 65, entitled to Medicare due to disability and covered by a large group health plan from your work, or from a family member who is working, AND the employer has 100 or more employees

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