When is Medicare the primary payer and when is it the secondary payer?

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Type of Insurance Conditions Primary Secondary
 
65+ with insurance based on current employment1 Less than 20 employees Medicare2 employer
20 or more Employees Employer Medicare
 
Disabled with insurance based on current employment3 Less than 100 employees Medicare Employer
100 or more employees Employer Medicare
 
End-Stage Renal Disease (ESRD or permanent kidney failure), with GHP or employer retiree plan During 30-month coordination period4 Employer/ Retiree5 Medicare
After the 30-month coordination period Medicare Employer/ Retiree
 
Personal Injury Insurance If available Personal injury insurance6 Medicare
 
Employer retiree plan7 Not eligible for Medicare Retiree N/A
Eligible for Medicare8 Medicare Retiree
 
COBRA Had COBRA before being enrolled in Medicare (Medicare eligible because of age, disability) or ESRD)9 Medicare COBRA terminates
Had Medicare before eligible for COBRA (Medicare eligible because of age or disability Medicare COBRA
Are under 65 and eligible for Medicare because of ESRD 10 COBRA (during 30-month coordination period) Medicare
 
1 You can have insurance based on your or your spouse's "current" employment. However, if coverage continues when you retire, it is considered retiree insurance. Retiree insurance works in a different way with Medicare than insurance based on current employment.

2 Companies with fewer than 20 employees may choose to offer primary coverage to employees over 65. If so, you should get it in writing from your employer.

3 You can have insurance based on your, your spouse's or other family member's "current" employment. However, if coverage continues after retirement, it is considered retiree insurance. Retiree insurance works in a different way with Medicare than insurance based on current employment.

4 The 30-month coordination period starts when you first enroll in Medicare based on ESRD or the first month you would have qualified if you had applied for Medicare ESRD benefits

5 For those on Medicare due to End-Stage Renal Disease, an employer group health plan�s primary payer status does not depend on current employment.

6 Includes workers' compensation and liability insurance or claims. Medicare may make conditional payments until liability claims are settled.

7 An employer retiree plan is health care coverage that is available from a former employer upon retirement.

8 Due to age or disability, but not ESRD.

9 Although employers have the right to end COBRA coverage when you enroll in Medicare, some employers choose to continue COBRA. If your COBRA coverage continues when you enroll in Medicare, then Medicare is primary. This is only true if you qualify for Medicare based on age or disability. If you enroll in Medicare because of ESRD, and your employer does not end COBRA, then COBRA is primary and Medicare is secondary during the 30-month coordination period.

10 If you enroll in Medicare before you qualify for COBRA, your employer must offer you COBRA. If you enroll in Medicare after you get COBRA, your employer can, (but does not have to) end your COBRA coverage.

 

 

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GO TO
Can I have both COBRA and Medicare?

Do I need Medicare if I have retiree insurance?

Enrolling in Medicare Part B if you are 65 or older, still working (or spouse is still working) and have insurance from that job

How do I know whether my employer coverage or Medicare is primary?

Should I enroll in Medicare if I have health insurance from my (or my spouse's) current employer?

 
LINKS
COBRA Information - Department of Labor

American Kidney Fund

National Forum of End-Stage Renal Disease (ESRD) Networks

National Institute of Diabetes and Kidney Diseases (NIDDK)

 
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