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How Does My Group Health Insurance Work with Medicare?

| November 09, 2022
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You are Medicare eligible and have group health insurance provided by you or your spouse’s current employer. Can I have Medicare and my group plan? Do they work together? To keep it simple, yes, and yes, but there are certain rules that determine whether Medicare or your group coverage pays first.  

Important facts to remember about how other insurance works with Medicare-covered services:  

  • The insurance that pays first (primary payer) pays up to the limits of its coverage. 
  • The insurance that pays second (secondary payer) only pays if there are costs the primary payer didn’t cover. 
  • The secondary payer (which may be Medicare) might not pay all the uncovered costs. 
  • If your group health plan or retiree health coverage is the secondary payer, you might need to sign up for Medicare Part B before your insurance will pay.

Let’s go through a few common examples. 

       You are 65 or older, have a group health plan coverage based on your or your spouse’s current employment, and the employer has 20 or more employees.  Your group health insurance plan pays first

       You are 65 or older, have a group health plan coverage based on your or your spouse’s current employment, and the employer has fewer than 20 employees. Medicare pays first

       You have a group health plan coverage based on your or a family member’s employment or former employment, and you’re eligible for Medicare because of End-Stage Renal Disease (ESRD). Your group health plan pays first for the first 30 months after you become eligible for Medicare. Medicare pays first after this 30-month period

       If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has 100 or more employees…Your group health plan pays first.

       If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has fewer than 100 employees. Medicare pays first

       You have TRICARE. Medicare pays first, unless you’re on active duty, or get items or services from a military hospital or clinic, or other federal health care provider

You have Medicaid. Medicare pays first.

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