Is Medicare or Work Insurance Primary

By Ed Crowe | | 0 comment | 27 July, 2017 | 0

Is Medicare or work insurance primary

Many people are confused about weather Medicare or work insurance is their primary insurance. So is medicare or work insurance primary? It depends on the situation and can have a big effect on your client. The size of the employer makes the difference. Read below for more details.

If your employer has fewer than 20 employees, Medicare generally pays first.

But, Medicare would generally pay second if both of these apply:

Your employer joins with other employers or employee organizations (such as unions or other commonly owned companies) to sponsor a group health plan (called a multi-employer plan). You can also use common ownership to group companies together. This may lead to a very small group having more than 20 employees.
Any of the other employers have 20 or more employees

Your plan might also ask for an exception. So, even if your employer has fewer than 20 employees, you’ll need to try to find out from your employer if Medicare pays first or second.

Is Medicare or work insurance primary for those that are under age 65 but on medicare due to a disability?

Generally, if your employer has fewer than 100 employees, Medicare pays first if you’re under 65 or you have Medicare because of a disability. Sometimes employers with fewer than 100 employees join with other employers to form a multi-employer plan or multiple employer plan. If at least one employer in the multi-employer plan or multiple employer plan has 20 employees or more, Medicare pays second.

In fact, if the employer has at least 100 employees, the health plan is a large group health plan. If you have insurance through a large group health plan because of either your or a family member’s current employment, Medicare pays second.

If you go outside your employer plan’s network, it’s possible that neither the employer plan nor Medicare will pay. You should call your employer before you go outside the network to find out if the service will be covered.

If the employer has 20 or more employees, the group health plan will pay first.

If the group health plan didn’t pay all of your bill, the doctor or health care provider should send the bill to Medicare for secondary payment. Medicare will pay based on what the group health plan paid, what the group health plan allowed, and what the doctor or health care provider charged on the claim. You’ll have to pay whatever costs Medicare or the group health plan doesn’t cover.

Employers with 20 or more employees must offer current employees 65 and older the same health benefits, under the same conditions, that they offer employees under 65. The employer must cover the same percentage of cost for both populations. If the employer offers spousal coverage, the employer must offer the same spousal coverage to people 65 and older. In some cases it may be more cost effective for the employee to come off the group health plan and enroll in Medicare part B.