Who will pay first? – InsuranceNewsNet


I am 67 years old and have group health insurance with my current employer. I spoke with friends, my company HR, and my insurance agent and got responses from “I don’t know” to “I’m not sure but I think…”. My company’s health insurance has a high deductible. If I have a medical claim and I have Medicare Part A and my employer’s health insurance, who will pay the claim first and how much will I have to pay? Also, should I register for Medicare Part B since I am still working?

I just started following your Medicare column in our local newspaper and I see you responding to issues I didn’t know I might have. Thank you very much.

Roxane, Pacific Palisades, California



Let’s start by discussing enrollment in Medicare Part B when working with an employer group health plan. The Medicare & You manual deals with “Do I get Part B” with employer or union coverage and states … “If you or your spouse is still working and you have health coverage through from that employer or union, contact your employer or benefits administrator to find out how your coverage with Medicare works… It may be beneficial to delay enrollment in Part B. “

To answer about enrolling in Medicare Part B, this is optional because when you leave your employer’s or spouse’s group health plan, then you can enroll in Medicare Part B with a period of special inscription.

Now let’s talk about who will pay your claim first and it depends on the number of employees affiliated with your company’s group health insurance plan:

* Your employer has 20 or more employees. Your group health plan will generally be primary. If your group health plan doesn’t pay the full bill, you may need to ask the health care provider or your doctor to send the rest of the bill to Medicare if you are enrolled in Medicare Parts A and / or B for the secondary payment. If there are any charges that your health insurance or Medicare did not cover, you will have to pay the balance.

The employer must offer his employees aged 65 and over the same health services, under the same conditions, that he offers to employees under the age of 65.

* Your employer has less than 20 employees. Medicare pays first. Speak with your employer’s human resources department or your employer’s health insurance agent to determine whether to enroll in Medicare Parts A and / or B, as a small number of insurance plans– illnesses require employees employed by companies with group health plans covering 20 or fewer employees to enroll in Medicare Part B. The CMS L-564 “Request for Employer Information” form is available to employees. still working “after age 65 with genuine employer insurance to avoid the Medicare Part B penalty.” This form is available to an employee and their spouse who enroll in Medicare Part B after age 65. * Remember that the Medicare Medigap / Six-Month Supplement enrollment period begins when you first enroll in Medicare Part B *

* Your employer has less than 20 employees. The small employer joins forces with other employers or employers’ organizations, that is to say unions, to sponsor a multi-employer plan (collective health plan). Sometimes employers with less than 100 employees come together to form a multi-employer plan. Medicare pays second.

Always check with your human resources to see if the Insurance company will pay first when employees or employees’ spouses are over 65 and on company health benefits.

* One thing to know is that if you need to get out of your employer’s network, it is possible that neither the company plan nor Medicare will pay.

For a health insurance check-up, call the Toni Says® Medicare Call Center at 832 / 519-8664 or send an email [email protected] regarding your health insurance plans and options. The Toni Says® Medicare Survival Guide is available at www.tonisays.com.

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