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Weight Loss Drugs and Medicare

If you are a Medicare agent, there is no doubt you have been asked about weight loss drugs and Medicare coverage. There is some big news for Medicare beneficiaries: starting in 2026, weight loss medications will be covered through a Medicare Part D pilot program. Thanks to recent deals between the Trump administration and drug makers Eli Lilly and Novo Nordisk, eligible clients can access these medications for just $50 per month, down from $1,000 or more.

Who Qualifies

Not everyone will be eligible. The program targets about 10% of Medicare enrollees with severe obesity or high-risk conditions:

• Severely obese (BMI > 35)
• Overweight (BMI > 27) with prediabetes or cardiovascular disease
• Obese with advanced kidney disease, heart failure, or uncontrolled hypertension

Medicare will cover about $245 per month, making the program affordable and accessible.

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How We Got Here

Initially, in April 2025, CMS decided not to cover anti-obesity medications due to high costs. Estimates suggested a potential $25–35 billion increase in spending over the next decade.

Everything changed in November 2025 when the Trump administration negotiated directly with manufacturers as part of the “Most Favored Nation” initiative. The result: a dramatic price drop that made coverage feasible without straining the Medicare budget.

TrumpRx: Option for Everyone

Even those who don’t qualify for Medicare coverage will have access to lower-cost medications starting January 2026 through TrumpRx.gov.

• Starting price: between $350 and $245/month
• Oral GLP-1 options expected pending FDA approval
• Available to anyone, regardless of insurance

What Medicare Covers Now

Before 2026, Medicare Part B covers obesity screenings and behavioral therapy, while Part D may cover GLP-1 drugs only if prescribed for diabetes or other approved conditions. Weight loss drugs are not otherwise covered.

Why This Matters for Agents

This is a game-changing opportunity for clients managing obesity or related health conditions. Agents can:

• Check Part D formularies for covered weight loss medications
• Compare plans for eligible clients
• Track policy updates in real time

The new coverage replaces compounded semaglutide options, giving clients access to brand-name medications at lower costs.

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Two Pricing Tracks

• Trump Deal (2026): $245/month to Medicare, $50 copay for eligible beneficiaries
• IRA Negotiations, put in place by the Biden administration, (2027): Could bring additional savings for Ozempic and Wegovy

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What seemed improbable months ago is now reality. By staying informed and guiding clients through their coverage options, agents provide real value during the 2026 enrollment season and beyond.

Why Medicare Supplement Rates Are Increasing

Many Medicare beneficiaries have recently noticed that their Medicare Supplement (Medigap) premiums are climbing; sometimes more than expected. The Medicare supplement rate increases can be frustrating, especially for retirees on fixed incomes. However, there are several factors driving these adjustments that help explain why costs are rising across the board.

Rising Healthcare Costs Nationwide

Healthcare costs in the United States continue to rise each year, driven by inflation in hospital charges, doctor fees, prescription drug prices, and medical technology. Medicare Supplement insurance companies base their premiums on the cost of paying future claims. As healthcare services become more expensive, insurers must collect more in premiums to keep up with the cost of covering beneficiaries’ care.

An Aging Policyholder Population

As people age, they typically require more frequent and costly medical care. Medicare Supplement plans, particularly those with long-standing enrollees, experience higher claim volumes as the average age of their members increases. When claims outpace the amount collected in premiums, insurers must adjust rates to remain financially stable.

Inflation and Administrative Expenses

General economic inflation affects almost every industry; including insurance. Administrative expenses such as employee wages, technology costs, and compliance requirements have all increased in recent years. Insurers incorporate these higher operating costs into their premium calculations, which contributes to annual rate increases.

Medical Advancements and Utilization

Medical advancements help seniors live longer and healthier lives, but they also come with higher price tags. New treatments, diagnostic tools, and specialized therapies often cost more than older alternatives. At the same time, people are using more healthcare services overall, from preventive screenings to outpatient procedures, raising total claim costs and, ultimately, premiums.

Plan Type and Rating Method

The way a Medicare Supplement plan is priced also affects future rate increases. There are three main rating methods:

• Community-rated: Everyone pays the same rate regardless of age. Increases are usually due to inflation or claim experience.
• Issue-age-rated: Rates are based on the age when you enroll; increases come from inflation and claims, not your age.
• Attained-age-rated: Rates start lower but increase as you age, plus inflation and claim adjustments.

Those enrolled in attained-age plans often experience the steepest long-term increases.

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Smaller Risk Pools and Market Shifts

As Medicare Advantage enrollment continues to grow, fewer people are buying new Medicare Supplement plans. A smaller pool of members means less spread of risk, which can cause rates to rise faster for remaining policyholders. Additionally, some carriers exit certain states or discontinue specific plans, leaving fewer options and less competition.

Watch a video on the special enrollment periods for discontinued Medicare advantage plans

Managing Future Increases

While rising premiums are often unavoidable, beneficiaries can take steps to manage their costs. Reviewing your plan annually, comparing rates from other carriers, or switching to a different Medigap plan type may help reduce expenses. Working with a licensed Medicare agent ensures you understand your options and can make informed decisions based on your health needs and budget.

Medicare Supplement rate increases reflect broader trends in healthcare spending, demographics, and the insurance market. While the numbers may fluctuate, understanding the reasons behind them helps seniors plan ahead and make the most of their Medicare coverage.

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Medicare General Enrollment Period – Who Can Use It

Medicare offers several enrollment windows, and knowing which one applies to your situation is essential for avoiding coverage gaps and late-enrollment penalties. One key enrollment period; especially for those who missed their initial opportunity, is the Medicare General Enrollment Period (GEP).

For those who didn’t sign up for Medicare when first eligible, the GEP may provide a second chance to enroll. Let’s break down what the GEP is, who qualifies to use it, and what to expect.

Understanding the Medicare General Enrollment Period

The Medicare General Enrollment Period runs every year from January 1 to March 31. It exists to help individuals who:

• Did not enroll in Medicare Part A and/or Part B during their Initial Enrollment Period (IEP), and
• Do not qualify for a Special Enrollment Period (SEP)

During the GEP, eligible individuals can sign up for Medicare Part A (if they have to pay a premium for it), Medicare Part B, or both.

Watch a YouTube video on Medicare Enrollment Periods

Who Can Use the GEP

You may be able to use the Medicare General Enrollment Period if:

1. You turned 65 and missed your Initial Enrollment Period
2. You left employer coverage and did not enroll during a Special Enrollment Period
3. You declined Medicare when first eligible and later changed your mind
4. You were not automatically enrolled and never completed enrollment

You cannot use the GEP if

You already enrolled or declined Medicare during your IEP or SEP
You currently qualify or applied for a Special Enrollment Period (for example, due to loss of employer coverage)

When Coverage Begins After Enrolling

Unlike past years when coverage began in July, Medicare’s updated rules mean that coverage starts the first day of the month after you enroll during the GEP.

For example:

• Enroll in January – Coverage starts February 1
• Enroll in March – Coverage starts April 1

What About Late-Enrollment Penalties

If you’re enrolling during the GEP because you didn’t qualify for a Special Enrollment Period, be aware that late-enrollment penalties may apply:

• Part B penalty: 10% increase for each full 12-month period you didn’t enroll when eligible
• Part A penalty: Applies if you’re required to pay a premium and delayed enrollment

These penalties typicallylast for a lifetime, so enrolling as soon as you’re eligible; or using a SEP if qualified, is critical.

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Can You Enroll in Medicare Advantage or Part D After the GEP

Yes. After enrolling in Medicare during the GEP, you have a Medicare Advantage and Part D enrollment window from April 1 to June 30 each year.

During this time, you can:

• Join a Medicare Advantage (Part C) plan
• Enroll in a standalone Part D prescription drug plan

Missing your Initial Enrollment Period doesn’t mean you’re out of options. The Medicare General Enrollment Period offers an important second chance to gain coverage, but acting promptly is key.

If you’re unsure whether you qualify for the GEP or a Special Enrollment Period, consider speaking with a licensed Medicare agent who can help you understand your enrollment options and avoid unnecessary penalties or coverage delays.

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Canceling Medicare Part B – What You Need to Know

Medicare Part B helps cover doctor visits, outpatient services, preventive care, and durable medical equipment. It’s a cornerstone of healthcare for many older adults. Although, there are some situations when cancelling Medicare Part B is the best option for you

Whether due to employer coverage, cost concerns, or personal circumstances, canceling Part B is a decision that needs careful consideration. Here’s what you should know before making the move.

Why Someone Might Cancel Part B

Most people keep Part B once they enroll, but in certain situations, canceling may make sense, such as:

• Returning to Employer Coverage
  If you or your spouse returns to work and gains coverage through a credible employer health plan, you may choose to cancel Part B to avoid paying the monthly premium.
• Cost Concerns
  Individuals on a fixed budget may reconsider Part B due to premium costs. However, this should be carefully weighed against healthcare needs.
• VA Benefits Only
  Some veterans rely solely on VA benefits and opt to drop Part B, though this comes with some risk if VA access is delayed or preferences change later.

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How to Cancel Medicare Part B

Canceling Part B isn’t as simple as clicking a button online. The Social Security Administration requires a signed request, and often a Form CMS-1763 must be completed. Typically, you will need to:

1. Contact Social Security by phone or visit your local office to request cancellation.
2. Complete Form CMS-1763 in person or by phone with a Social Security representative.
3. Confirm your disenrollment once processed.

This extra step is intentional; Medicare wants to be sure beneficiaries understand the consequences before dropping coverage.

Watch a YouTube video on Medicare Enrollment Periods

Important Considerations Before Canceling

Canceling Part B can have long-term implications. Here are key points to consider:

• You May Pay a Late Enrollment Penalty Later
  If you cancel and don’t have other credible coverage (like large-group employer insurance), you may face a permanent surcharge if you re-enroll later.
• Limited Re-Enrollment Windows
  You can’t re-enroll anytime. Most people must wait for the General Enrollment Period (January 1 – March 31), with coverage beginning July 1; potentially leaving gaps.
• Future Coverage Access
  If your health needs change unexpectedly, getting back into Medicare Part B isn’t immediate.
• Medigap Implications
  Canceling Part B can impact your ability to retain or buy a Medicare Supplement plan, since Part B is required to maintain Medigap coverage.

When Not to Cancel Part B

Avoid canceling Medicare Part B if:

You do not have other credible employer-based coverage
Your VA benefits are your only backup and you want broader provider access
You plan to enroll in a Medicare Advantage or Medigap plan; both require Part B

If you’re unsure, speak with a licensed Medicare agent before making changes.

Canceling Medicare Part B is possible, but it’s not a decision to take lightly. With potential penalties, waiting periods, and the importance of ongoing medical access, it’s essential to make sure you have another qualifying form of coverage in place first.

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If your circumstances have changed and you’re considering this step, be sure to talk with a Medicare expert who can help you understand the rules and avoid costly gaps in coverage.

Medicare Excess Charges: What They Are & How to Avoid Them

When navigating Medicare, many beneficiaries are surprised to learn about a lesser-known cost called Medicare excess charges. While not everyone will encounter them, knowing how they work, and how to avoid them, can help protect your wallet and ensure you receive the most value from your healthcare coverage.

What Are Medicare Excess Charges

Medicare excess charges occur when a healthcare provider charges more than the Medicare-approved amount for a service under Original Medicare Part B. In most cases, providers who accept Medicare agree to bill only the amount that Medicare approves. However, some providers do not accept Medicare assignment, meaning they can legally charge up to 15% more than the approved rate. This extra amount is known as the excess charge.

For example, if Medicare approves $200 for a service and pays 80% ($160), you’re responsible for the remaining 20% coinsurance ($40). If the provider adds a 15% excess charge ($30), you would owe $70 total instead of $40.

When Do Excess Charges Apply

Excess charges apply only to Medicare Part B services when a provider:

Accepts Medicare but
Does not accept Medicare assignment

These providers still treat Medicare patients, but they can bill above the standard Medicare fee schedule.

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Where Excess Charges Do Not Apply

You do not need to worry about excess charges if:

• You see a doctor who accepts Medicare assignment
• You receive care in a Medicare-participating facility
• You live in a state that bans excess charges (see below)
• You have a Medigap Plan G or Plan F (these plans pay excess charges)

States That Prohibit Medicare Excess Charges

Some states have passed laws to protect Medicare beneficiaries. In these states, providers cannot charge more than the Medicare-approved amount:

• Connecticut
• Massachusetts
• Minnesota
• New York
• Ohio
• Pennsylvania
• Rhode Island
• Vermont

If you live in one of these states, you are fully shielded from excess charges.

How to Avoid Medicare Excess Charges

Here are simple steps to ensure you don’t pay more than necessary:

1. Choose providers who accept Medicare assignment
2. Confirm billing practices before receiving care
3. Consider a Medigap plan (especially Plan G or Plan F) if you’re on Original Medicare
4. Use Medicare’s provider finder tool to verify assignment status

What About Medicare Advantage Plans

If you’re enrolled in a Medicare Advantage (Part C) plan, excess charges typically do not apply, as long as you stay within the plan’s network. Medicare Advantage plans negotiate rates with providers directly, separate from Original Medicare rules.

Medicare excess charges aren’t common, but when they do occur, they can add up. The good news is that with the right knowledge and a little planning you can easily avoid them. Whether you choose Original Medicare with a Medigap plan or enroll in Medicare Advantage, being proactive about your provider choices helps ensure your healthcare is both high-quality and cost-effective.

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Deductibles and Other Medical Costs: What They Mean for Your Healthcare Budget

Healthcare terms can feel confusing, especially when it comes to how much you’ll actually pay for medical services. One of the most important pieces to understand when choosing insurance, or reviewing your current coverage, are deductibles and other medical costs.

These costs directly impact what you spend before your insurance steps in and how much you’re responsible for throughout the year. Understanding them helps you plan better, compare plans accurately, and avoid unexpected medical bills.

What Is a Deductible

A deductible is the amount you must pay for covered healthcare services before your insurance begins to share the costs.

For example, if your deductible is $2,500, you pay the first $2,500 of covered medical expenses yourself. After you meet your deductible, your insurance typically starts paying a portion of costs (often through coinsurance).

Think of the deductible as your first layer of financial responsibility in your insurance plan.

What Are Out-of-Pocket Costs

Out-of-pocket costs are expenses you’re responsible for when receiving care. They may include:

• Deductibles
• Copayments (fixed dollar amounts per service)
• Coinsurance (a percentage of the cost of services)
• Non-covered services

When comparing plans, look not only at the deductible but also the overall cost-sharing structure. A low-deductible plan may have higher premiums but lower out-of-pocket expenses when you receive care and vice versa.

Understanding the Out-of-Pocket Maximum

Most health insurance plans also include an out-of-pocket maximum (OOPM). This is the most you’ll pay in a policy year for covered services. Once you reach that limit, your insurance covers 100% of eligible expenses for the remainder of the year.

This limit is an important financial safeguard, especially for individuals with chronic conditions or unexpected medical events.

Watch a Video on Medicare IRMAA & Part B SEP Rules

Why Your Deductible and OOP Spending Matter

Knowing your deductible and out-of-pocket maximum helps you:

• Budget healthcare expenses
• Select a plan that fits your needs
• Avoid surprises when receiving care
• Plan ahead for prescriptions, specialists, or procedures
• Understand how preventive services are covered (This is key; many preventive services are covered before deductible!)

Tips for Choosing the Right Plan

When evaluating health plans, consider:

• How often you visit doctors
• Whether you take ongoing prescriptions
• Expected medical needs (e.g., planned surgery, therapies)
• Monthly premium cost versus potential annual expenses
• Your comfort level with risk and unexpected bills

People who expect regular medical care may benefit from lower deductibles and higher premiums. Those who rarely seek care may prefer a lower-premium, higher-deductible option.

Deductibles and out-of-pocket costs aren’t just insurance jargon; they are vital components of your financial health plan. Understanding them helps you to make smarter decisions and choose coverage that protects both your health and your wallet.

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If you ever feel uncertain about comparing plans or estimating potential costs, don’t hesitate to ask questions. Being informed is the first step to confident healthcare decisions. That is why working with a licensed insurance agent is so important.

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Medicare SSBCI vs. VBID: What’s the Difference

Two major innovations in the Medicare Advantage (MA) program; special supplemental benefits for the chronically Ill (SSBCI) and the Value-Based Insurance Design (VBID) Model, both aim to improve outcomes for beneficiaries with chronic conditions. However, they differ in purpose, eligibility, benefits, and future outlook. Here’s what you should know about Medicare SSBCI vs VBID and how they compare.

What Is SSBCI

The Special Supplemental Benefits for the Chronically Ill (SSBCI) program was created under the Bipartisan Budget Act of 2018. It allows Medicare Advantage plans to offer non-traditional, non-medical benefits designed to help people with serious chronic illnesses maintain or improve their health and daily function.

To qualify, a beneficiary must:

1. Have one or more complex chronic conditions,
2. Be at high risk of hospitalization or other negative outcomes, and
3. Require intensive care coordination.

Unlike standard Medicare benefits, SSBCI may cover services such as healthy groceries, home air-quality equipment, pest control, transportation, or home modifications. These benefits address social factors that affect health, such as nutrition, housing, and access to care.

Watch a YouTube video on the prescription payment program

SSBCI benefits are optional, meaning not every MA plan offers them. Plans also decide what types of benefits to include and who qualifies. CMS is increasing oversight to ensure these benefits are supported by evidence showing they can improve or maintain a member’s health or function.

SSBCI represents a shift in Medicare Advantage toward whole-person care; addressing more than just medical needs.

What Is VBID?

The Value-Based Insurance Design (VBID) Model, launched by the CMS Innovation Center, allowed participating Medicare Advantage plans to align cost-sharing and benefits with the clinical value of care. The goal was to lower barriers to high-value care (like preventive services or chronic disease management) while discouraging unnecessary spending.

VBID gave participating plans flexibility to reduce copays, expand supplemental benefits, and even test hospice care integration within MA. These features often targeted individuals with chronic illnesses, low income, or those living in underserved areas.

However, VBID was a demonstration model, not a permanent part of Medicare. In 2025, CMS announced it will end the VBID Model after determining that program costs to Medicare were higher than anticipated. While the model is ending, many of its design ideas; like targeted cost-sharing and flexible benefits, are expected to influence future MA benefit structures.

SSBCI vs. VBID: A Quick Comparison

Why It Matters

Both programs reflect a growing focus on integrated, person-centered care in Medicare Advantage.

• For beneficiaries: SSBCI can provide meaningful extra help for daily living and health support, but eligibility rules apply. Not everyone in an MA plan will qualify.
• For VBID participants: The model’s end may change how some plan benefits are structured in 2026, but many innovations are expected to remain.
• For all MA enrollees: When comparing plans, look beyond premiums and copays. Review whether a plan offers SSBCI or other supplemental benefits that fit your personal needs.

Always review your plan’s Summary of Benefits and Evidence of Coverage to see if SSBCI options are available, and confirm your eligibility with the plan.

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SSBCI and VBID have both pushed Medicare Advantage toward smarter, more holistic care. While VBID will conclude in 2025, SSBCI continues to grow; helping address many factors that shape health outcomes. Together, they represent Medicare’s evolving goal: not just to pay for medical care, but to help beneficiaries live healthier, more independent lives.

Humana Medicare 2026 OTC Benefits: How to Use and Access Them

Many Humana Medicare Advantage (Part C) plans include an over-the-counter (OTC) allowance to help members save on everyday health items. Fortunately, Humana Medicare 2026 OTC benefits provides members more ways to maintain their health while managing out-of-pocket costs.

What the OTC Benefit Covers

Humana’s OTC benefit allows members to buy non-prescription health and wellness products at no cost, up to a set allowance. Covered items typically include:

• Pain relievers and cold medicines
• Vitamins and supplements
• Dental care items like toothbrushes and toothpaste
• First-aid and wound-care supplies
• Digestive aids and bladder-control products

Depending on the plan, members may receive a monthly or quarterly allowance to spend. Some plans offer rollover options, while others require that unused funds be used within the benefit period.

Watch a YouTube video on Medicare Advantage vs Medicare Supplements

How to Access Your OTC Benefit

1. Confirm Eligibility – Log into your MyHumana account or review your Summary of Benefits to confirm your plan includes an OTC allowance. You can also call the Member Services number on your Humana ID card.
2. Know Your Allowance – Find out how much you receive and how often it renews. Available benefits vary by plan and region.
3. Shop for Eligible Items – You can use your OTC funds in several ways:
   • Humana Spending Account Card – Many plans load your allowance onto a prepaid card you can use at participating retailers.
   • Mail Order or Online Catalog – Some plans require ordering through CenterWell Pharmacy’s OTC catalog or online store.
4. Use It Before It Expires – Most allowances expire at the end of each benefit period or at year-end. Check your balance often to avoid losing unused funds.

Tips to Maximize the Benefit

• Review Plan Changes Annually: OTC benefits and amounts can change each year. Always read your Annual Notice of Change (ANOC) each fall.
• Shop Early and Smart: If mail order is required, place orders early to allow for shipping time.
• Combine Benefits: Some Humana plans that include Healthy Options or grocery allowances encourage clients to take advantage of all available extras.
• Keep Receipts: If questions arise, documentation helps confirm eligible purchases.
• Ask for Help: Members can contact Humana Member Services or their licensed agent for guidance.

Why This Benefit Matters

Humana’s OTC benefit helps reduce the cost of everyday health items, adding value to Medicare Advantage coverage. For 2026, these allowances highlight Humana’s focus on affordability and wellness. When clients understand and use these benefits fully, they save money, improve their health, and feel more satisfied with their plan.

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Understanding Coordinated Care: How It Improves Health

When it comes to your health, it’s not uncommon to see several doctors, specialists, or therapists over time. But have you ever wondered who’s making sure everyone is on the same page about your care? That’s where understanding coordinated care comes in. This is an approach designed to keep healthcare connected, organized, and focused on the patient as a whole.

What Is Coordinated Care

Coordinated care is a healthcare model that ensures all members of the care team; from primary care providers to specialists, hospitals, and even pharmacists, work together to manage overall health. The goal is simple: to deliver high-quality care that meets healthcare needs while reducing confusion, delays, and unnecessary costs.

Instead of treating each health concern in separately, coordinated care looks at your entire health picture. It’s a team-based, patient-centered approach that emphasizes communication and collaboration across all your healthcare providers.

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How Coordinated Care Works

In a coordinated care system, one provider (often your primary care physician or a dedicated care manager) takes the lead in managing your treatment plan. This person acts as your main point of contact and ensures that:

• Providers share test results and medical records to forma treatment plan
• Treatments don’t overlap or conflict
• You understand your medications and next steps
• Your transition between care settings; such as from hospital to home, goes smoothly

This kind of teamwork helps prevent medical errors, unnecessary repeat tests, and medication mix-ups that can happen when care is fragmented.

Examples

• A person living with diabetes might see a primary care doctor, an endocrinologist, and a nutritionist. In coordinated care, these professionals communicate regularly to align medications, diet recommendations, and follow-up visits.
• After a hospital discharge, a care coordinator might help schedule follow-up appointments, review discharge instructions, and ensure the patient fills their prescriptions; reducing the chance of readmission.
• Many Medicare Advantage and Accountable Care Organizations (ACOs) use coordinated care models to deliver more efficient and effective care for members.

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Why Coordinated Care Matters

Coordinated care isn’t just about organization; it’s about better outcomes. When providers share information and work together, you benefit from:

• Improved overall health
• Fewer hospital visits
• Lower out-of-pocket costs
• Greater satisfaction with your care

Most importantly, it ensures that care reflects your personal goals, preferences, and lifestyle because no one’s health journey looks the same.

Coordinated care is about putting the patient back at the center of the healthcare experience. By connecting the dots between your doctors, specialists, and support services, coordinated care leads to smarter, safer, and more compassionate healthcare.

Whether you’re managing a chronic condition or just want a smoother healthcare experience, coordinated care helps ensure that every part of your health story fits together the way it should.

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Medicare as Primary Insurance

When you turn 65 or qualify for Medicare due to disability, one of the most important things to know is whether Medicare becomes your primary or secondary insurance. Understanding Medicare as primary insurance helps avoid billing issues and unexpected out-of-pocket costs.

What Does “Primary” Mean

The primary payer is the insurance that pays your medical bills first. The secondary payer may cover costs that the primary insurance doesn’t pay; such as deductibles, coinsurance, or copays.
When Medicare is your primary insurance, your healthcare providers bill Medicare first. Once Medicare pays its share, any remaining balance may be sent to your secondary insurance, such as an employer plan or Medigap policy.

When Medicare Is Primary

Medicare typically pays first in these situations:

1. You’re retired and not covered by active employer insurance.
   Once you stop working and lose active coverage from an employer, Medicare becomes your primary insurance.
2. You have a small employer plan (fewer than 20 employees).
   If you’re still working or covered under a spouse’s small employer plan, Medicare pays first.
3. You have retiree coverage.
   Retiree insurance or COBRA coverage always pays after Medicare.
4. You have no other insurance.
   If Medicare is your only health coverage, it’s automatically primary.
5. You’re covered by Medicaid.
   Medicaid is always the payer of last resort, so Medicare pays first.

Learn about Medicare and employer coverage

When Medicare Is Secondary

In some cases, Medicare may pay after another insurance plan:

• You or your spouse are actively working for an employer with 20 or more employees, and you’re covered under that employer’s health plan.
• You’re receiving workers’ compensation or have a claim covered under no-fault or liability insurance.
• You’re under age 65 and have employer coverage due to disability, and the employer has 100 or more employees.

In these situations, your employer or other insurance must pay first, and Medicare acts as a secondary payer.

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Why It Matters

Knowing when Medicare is primary ensures your medical claims are processed correctly. If you enroll in Medicare but fail to tell your other insurer, or vice versa, you could face denied claims or late enrollment penalties.
Always confirm your coverage status with both Medicare and your employer’s benefits administrator to avoid costly mistakes.

Medicare’s role; whether it’s primary or secondary, depends on your work status, the size of your employer, and any additional coverage you may have.
If you’re nearing retirement or changing jobs, take time to review how your coverage coordinates. Doing so helps ensure smooth billing and gives you peace of mind knowing your healthcare costs are properly covered.

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