Medicare as Primary Payer

Q: At a recent doctor’s appointment, I was asked if Medicare was my primary payer. I do have Medicare, but what does that mean?

A: The term “payer” generally refers to Medicare and/or any other type of health care coverage you may have. The primary payer is responsible for paying their share of the bill first. The secondary payer would pay next, and, in some cases, there could be a third payer.

If you have a Medicare Supplement Plan (Medigap), Medicare is the primary payer. That means Medicare pays their portion of the bill before your Supplement makes their payment for deductibles and co-pays not covered by Medicare.

If you have a Medicare Advantage Plan, you’ll still have Medicare but you’ll get your Part A and Part B coverage from the Medicare Advantage Plan rather than Original Medicare. A Medicare Advantage plan is usually primary over any other coverage and includes deductibles and co-pays that you will have to pay yourself.

If you are 65 or older and covered by a group health plan because you or your spouse is still working, the primary payer depends on the size of the company.  If the company has 20 or more employees, the group health care plan pays first. If the company has fewer than 20 employees, Medicare is the primary payer.

* If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will pay. Secondary insurance will pay for non-covered Medicare services. So unlike Medigap coverage, it would not cover the deductibles and co-pays for Medicare.

If you have an employer group health plan through your former employer after you retire and are 65 or older, Medicare pays first and your retirement coverage pays second.

If you have both Medicare and Medicaid, Medicare would be the primary payer.

If you are disabled and covered by a large group health plan from your work, or from a family member who’s working and the employer has 100 or more employees, the group health plan will be the primary player. If the employer has fewer than 100 employees, Medicare will be the primary payer.

If you are 65 or older and have Veterans’ benefits, Medicare pays for Medicare-covered services or items. Veterans’ Affairs pays for VA-authorized services or items.

Tricare members are converted to Tricare for Life when they enroll in Medicare and serves as a Medicare supplement in most cases. Tricare for Life members must enroll in Medicare Part B. Medicare pays its portion first and sends the claim to the TRICARE for Life claims processor.

Have questions about Medicare payers or any other questions about Medicare, call SHIP at 1-800-452-4800, 1-866-846-0139 TDD or online at www.medicare.in.gov.