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

Section VII.a. Overview of Options for Filling the Gaps in Medicare

Question 4 of 5 (use "Last" or "Next" buttons to see more)

Last Update: August 12, 2010

Type of Insurance	Conditions	Primary	Secondary

65+ with insurance based on current employment¹	Less than 20 employees	Medicare²	employer
65+ with insurance based on current employment¹	20 or more Employees	Employer	Medicare

Disabled with insurance based on current employment³	Less than 100 employees	Medicare	Employer
Disabled with insurance based on current employment³	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
Employer retiree plan⁷	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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