How Medicare works with other insurance (2024)

FAQs

How does Medicare work with other insurances? ›

The "primary payer" pays up to the limits of its coverage, then sends the rest of the balance to the "secondary payer." If the “secondary payer” doesn't cover the remaining balance, you may be responsible for the rest of the costs.

The insurance that pays first is called the primary payer. The primary payer pays up to the limits of its coverage. The insurance that pays second is called the secondary payer. The secondary payer only pays if there are costs the primary insurer didn't cover.

If you have Medicare because you're 65 or older, Medicare pays first. If you have COBRA and you're eligible for Medicare: COBRA may only pay a small portion of your medical costs. You may have to pay most of the costs yourself.

It is possible to have both private insurance and Medicare at the same time. When you have both, a process called “coordination of benefits” determines which insurance provider pays first. This provider is called the primary payer.

Once you stop working (or lose your health insurance, if that happens first) you have an 8-month Special Enrollment Period (SEP) when you can sign up for Medicare (or add Part B to existing Part A coverage).

Having two health insurance policies doesn't mean you'll be covered twice by both plans. For example, if you sprain your ankle and go to the doctor, your visit isn't going to be reimbursed multiple times. Both plans may cover some of the expenses, but the combined benefits won't surpass the total cost of your visit.

Medicare doesn't automatically know if you have other coverage. But your insurers must report to Medicare when they're the primary payer on your medical claims. In some situations, your healthcare provider, employer or insurer may ask questions about your current coverage and report that information to Medicare.

If the primary payer denies the claim because of liability, the no-fault or WC insurer must place the reason for denial on the claim, which you can find on your remittance advice that you'll send to Medicare. Without this reason, Medicare will deny the claim.

Coordination of Benefits

Your primary coverage plan, either Medicare or private, will pay for covered medical expenses. Then, your secondary plan will cover additional costs. Both insurance plans will communicate with each other to ensure there aren't duplicate payments.

Will Medicare pay my deductible from my primary insurance? ›

Medicare as secondary insurance often referred to as “Medigap” or Medicare Supplement Insurance plan, works by filling the gaps left by Original Medicare. It covers deductibles, co-payments, and other out-of-pocket costs that the primary insurance doesn't cover, reducing the financial burden.

There are some things Original Medicare won't cover. Generally, most vision, dental and hearing services are not covered by Medicare Parts A and B. Other services not covered by Medicare Parts A and B include: Routine physical exams.

In some cases, you'll have a higher share of costs when you see an out-of-network doctor. In other cases, you're not covered at all if you go out of network. This is particularly important if you travel a lot because Medicare Advantage plans generally don't provide out-of-state coverage.

Many people choose to keep working past 65 and keep their coverage under their employer's group plan. But if you've been paying into Medicare via payroll deductions, you may as well enroll in Original Medicare Part A (hospital insurance) when you're first eligible, as you'll pay no premium.

Supplemental insurance is advisable for those with Medicare to help cover out-of-pocket costs and gaps in coverage, offering financial protection for deductibles, coinsurance, and other medical expenses not fully covered by Medicare.

Supplemental insurance is advisable for those with Medicare to help cover out-of-pocket costs and gaps in coverage, offering financial protection for deductibles, coinsurance, and other medical expenses not fully covered by Medicare.

Marriage and Medicare

Your marital status doesn't affect your coverage, so you don't gain or lose coverage by getting married or divorced. (The only thing it really does affect is whether or not you pay a premium for Medicare Part A and how much you pay for your Medicare Part B premium, but we'll get to that later.)

Having Medicare as a secondary payer offers several benefits. It can help reduce out-of-pocket expenses, as Medicare may cover costs that your primary insurance does not. This can include deductibles, copayments, and coinsurance.

Can I get a Marketplace plan in addition to Medicare? No. It's against the law for someone who knows you have Medicare to sell you a Marketplace plan. This is true even if you have only Medicare Part A (Hospital Insurance) or only Medicare Part B (Medical Insurance).