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C E N T E R S F O R M E D I C A R E & M E D I C A I D S E R V I C E S

Medicare & Other Health Benefits:

Your Guide to

Who Pays First

This official government

booklet tells you:

• How Medicare works with othertypes of coverage

• Who should pay your bills first

• Where to get more help



IntroductionHow this guide can help you

Some people with Medicare have other health coverage that must pay

before Medicare pays its share of the bill. This guide tells how Medicare

works with other kinds of coverage and who should pay your bills first.

Tell your doctor, hospital, and all other health care providers about your

other health coverage to make sure your bills are sent to the right payer

to avoid delays.

Where can I get basic information about Medicare?

Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users

should call 1-877-486-2048.

https://medicare.gov/




3

Table of contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

When you have other health coverage . . . . . . . . . . . . . . . . . . . . 5

Who pays first i I have other health coverage? . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Where to go with questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

How Medicare coordinates with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Medicare & other types of health coverage . . . . . . . . . . . . . . . . . 11

Medicare & Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Medicare & group health plan coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Medicare & group health plan coverage afer you retire. . . . . . . . . . . . . . . . . . . 13

Medicare & group health plan coverage or people who are disabled(non-ESRD disability) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Medicare & group health plan coverage or people with End-StageRenal Disease (ESRD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Medicare & no-ault or liability insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Medicare & workers’ compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Medicare & Veterans’ benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Medicare & RICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Medicare & the Federal Black Lung Benefits Program . . . . . . . . . . . . . . . . . . . 26

Medicare & COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Section 1:

Section 2:

Section 3:

Section 4:



4

Welcome to Medicare & Other Health Benefits:

Your Guide to Who Pays First

The information in this booklet describes the Medicare

program at the time this booklet was printed. Changes

may occur after printing. Visit Medicare.gov, or call

1-800-MEDICARE (1-800-633-4227) to get the most current

information. TTY users should call 1-877-486-2048.

“Medicare & Other Health Benefits: Your Guide to Who

Pays First” isn’t a legal document. Official Medicare

Program legal guidance is contained in the relevant

statutes, regulations, and rulings.





5

SECTION

1When you have other

health coverage

Who pays first if I have other health coverage?

I you have Medicare and other health coverage, each type o coverage is calleda “payer.” When there’s more than one payer, “coordination o benefits” rulesdecide who pays first. Te “primary payer” pays what it owes on your bills first,and then your provider sends the rest to the “secondary payer” to pay. In somecases, there may also be a “third payer.”

Whether Medicare pays first depends on a number o things, including thesituations listed in the chart on the next 2 pages. However, this chart doesn’tcover every situation. Be sure to tell your doctor and other health careproviders i you have health coverage in addition to Medicare. Tis will helpthem send your bills to the correct payer to avoid delays.

Note: Paying “first” means paying the bill up to the limits o the payer’scoverage. It doesn’t always mean the primary payer pays first in time.

Where to go with questions

If you have questions about who pays first, or if your coverage changes,

call the Benefits Coordination & Recovery Center (BCRC) toll-free at

1-855-798-2627. TTY users should call 1-855-797-2627.

o better serve you, have your Medicare number ready when you call. You can

find your Medicare number on your red, white, and blue Medicare card.You also may be asked or additional inormation, like:

• Your Social Security Number (SSN)

• Address

• Medicare effective date(s)

• Whether you have Medicare Part A (Hospital Insurance) and/orMedicare Part B (Medical Insurance) coverage

Words in purple

are defined on

pages 29–30.



6 Section 1: When you have other health coverage

How Medicare coordinates with other coverage

Use the chart below to find your type(s) o coverage and situation to see which payer pays first:

If you Situation Pays first Pays second Page(s)

Are covered byMedicare andMedicaid

Entitled to Medicare andMedicaid Medicare Medicaid, butonly afer othercoverage (likeemployer grouphealth plans) haspaid

11

Are 65 or older andcovered by a grouphealth plan becauseyou or your spouse isstill working

Entitled to Medicare

Te employer has 20 or moreemployees

Te employer has less than 20employees*

Group health plan

Medicare

Medicare

Group health plan

12

12

Have an employergroup health planthrough your ownormer employer aferyou retire and are 65or older

Entitled to Medicare Medicare Retiree coverage 13–15

Are disabled andcovered by a largegroup health plan rom your work,

or rom a amilymember (like spouse,domestic partner,son, daughter orgrandchild) who isworking

Entitled to Medicare

Te employer has 100 or moreemployees

Te employer has less than 100employees

Large grouphealth plan

Medicare

Medicare

Group health plan

15

15

**Have End-StageRenal Disease (ESRD) (permanent kidneyailure requiringdialysis or a kidney

transplant) andgroup health plancoverage (including aretirement plan)

First 30 months o eligibility orentitlement to Medicare

Afer 30 months o eligibility orentitlement to Medicare

Group health plan

Medicare

Medicare

Group health plan

16

16

Have ESRD andCOBRA coverage

First 30 months o eligibility orentitlement to Medicare on thebasis o ESRD

Afer 30 months

COBRA

Medicare

Medicare

COBRA

27

16

* I your employer participates in a plan that’s sponsored by 2 or more employers, the rules are slightly different.

** I you originally got Medicare due to your age or a disability other than ESRD, and Medicare was your primary payer, it still pays firstwhen you become eligible due to ESRD.



7Section 1: When you have other health coverage

If you Situation Pays first Pays second Page(s)

Are 65 or over ORdisabled and coveredby Medicare andCOBRA coverage

Entitled to Medicare Medicare COBRA 26–27

Have been in anaccident whereno-ault or liabilityinsurance is involved

Entitled to Medicare No-ault or liabilityinsurance or servicesrelated to accident claim

Medicare 17–19

Are coveredunder workers’compensation because o a job-related illness orinjury

Entitled to Medicare Workers’ compensationor services related toworkers’ compensationclaim

Usually doesn’tapply. However,Medicare maymake a conditionalpayment (a paymentthat must be repaidto Medicare whena settlement, judgment, award,or other payment ismade.)

19–23

Are a Veteran andhave Veterans’

benefits

Entitled to Medicareand Veterans’ benefits

Medicare pays orMedicare- covered

services.Veterans’ Affairs pays orVA-authorized services.

Note: Generally,Medicare and VA can’tpay or the same service.

Usually doesn’t apply 23–24

Are covered underRICARE

Entitled to Medicareand RICARE

Medicare pays orMedicare- coveredservices.

RICARE pays or

services rom a militaryhospital or any otherederal provider.

RICARE may paysecond.

24–25

Have black lungdisease and arecovered under theFederal Black LungBenefits Program

Entitled to Medicareand the Federal BlackLung Benefits Program

Te Federal Black LungBenefits Program orservices related to blacklung.

Medicare 26

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How Medicare coordinates with other coverage

I’m not yet 65. How will Medicare know I have other coverage?

About 3 months beore you get Medicare, Medicare will send you a letter witha username and password or MyMedicare.gov . Tis is a ree, secure onlineservice where you can keep personalized inormation on your Medicare benefitsand services. Medicare doesn’t automatically know i you have other coverage.Fill out your “Initial Enrollment Questionnaire” (IEQ) at MyMedicare.gov tomake sure your medical bills are paid correctly and on time.

Te IEQ asks i you have group health plan coverage through your work or aamily member’s work. Medicare uses your answers to help set up your file andmake sure your claims get paid correctly.

You can also complete your IEQ over the phone by calling the BenefitsCoordination & Recovery Center (BCRC) toll-ree at 1-855-798-2627.Y users should call 1-855-797-2627.

Example: Harry is almost 65 and is getting ready to retire and enroll inMedicare. Harry’s wie Jane, 63, works or a large company (more than 20people). Both Harry and Jane have health coverage through Jane’s employer’sgroup health plan.

Afer he gets a letter rom Medicare with his username and password orMyMedicare.gov , Harry goes to the website and fills out his IEQ. He reports hehas coverage through his wie’s employment. Tis insurance will pay Harry’sclaims first, and Medicare will pay Harry’s claims second.

What happens if my health coverage changes after I fill out the IEQ?

Call the BCRC and give this inormation:

• Your name

• Te name and address of your health plan

• Your policy number

• Te date coverage was added, changed, or stopped, and why

ell your doctor and other health care providers about changes in your coveragewhen you get care.

https://mymedicare.gov/








9Section 1: When you have other health coverage

How Medicare coordinates with other coverage (continued)

What if I have Medicare and more than one type of coverage?

Check your insurance policy—it may include the rules about who pays first.You can also call the Benefits Coordination & Recovery Center (BCRC) toll-reeat 1-855-798-2627. Y users should call 1-855-797-2627.

Where can I get more information about who pays first?

Call your health insurance plan’s benefits administrator. You can also call theBCRC.

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Notes



11

SECTION

Medicare & other types

of health coverage2 Medicare & Medicaid

Medicaid (also called Medical Assistance) is a joint ederal and stateprogram that helps pay medical costs or certain people and amilieswho have limited income and resources and meet other requirements.Medicaid never pays first for services covered by Medicare. It onlypays afer Medicare, employer group health plans, and/or MedicareSupplement Insurance (Medigap) policies have paid.

Medicare & group health plan coverage

You have a number o important decisions to make when you turn 65,like whether you should enroll in Medicare Part B (Medical Insurance),

join a Medicare Prescription Drug Plan, buy a Medigap policy, and/orkeep employer or retiree coverage. By understanding your choices, youcan avoid paying more than you need to, and get coverage that meets yourneeds.

Visit Medicare.gov/find-a-plan to compare Medicare health and drugplans in your area. You can also call your State Health InsuranceAssistance Program (SHIP). Visit Medicare.gov/contacts, or call1-800-MEDICARE (1-800-633-4227) to get the SHIP phone number.Y users should call 1-877-486-2048.

Should I get group health plan coverage?

Many employers and unions offer group health plan coverage to currentemployees or retirees. You may also get group health plan coveragethrough the employer o a spouse or amily member.

I you have Medicare and you’re offered coverage under a group healthplan, you can choose to accept or reject the plan. Te group health planmay be a ee-or-service plan or a managed care plan, like an HMO orPPO.

Words in purple

are defined on

pages 29–30.

https://medicare.gov/find-a-plan/questions/home.aspx

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12 Section 2: Medicare & other types of health coverage

Medicare & group health plan coverage (continued)

I have Medicare and group health plan coverage. Who pays first?

Generally, your group health plan pays first i both o these are true:

1. You’re 65 or older and covered by a group health plan through your current employer or the current employer o a spouse o any age.

2. Te employer has 20 or more employees and covers any o the same servicesas Medicare (this means the group health plan pays first on your hospital andmedical bills.)

I the group health plan didn’t pay all o your bill, the doctor or health careprovider should bill Medicare or secondary payment. Medicare will look

at what your group health plan paid, and pay any additional costs up to theMedicare-approved amounts as appropriate. You’ll have to pay whatever costsMedicare or the group health plan doesn’t cover.

I your employer has less than 20 employees, Medicare generally pays first. Buti your employer joins with other employers or employee organizations (likeunions) to sponsor a group health plan (called a multi-employer plan), and anyo the other employers has 20 or more employees, Medicare would generallypay second. However, your plan might ask for an exception, so even if your

employer has less than 20 employees, you’ll need to find out from your

employer whether Medicare pays first or second.

I’m in a Health Maintenance Organization (HMO) Plan or an employer

Preferred Provider Organization (PPO) Plan that pays first. Who pays if I go

outside the employer plan’s network?

I you go or care outside your employer plan’s network, you might not get anypayment rom your plan or Medicare. Call your plan beore you go outside thenetwork to find out i the service will be covered.

I decided not to take group health plan coverage from my employer. Will

this affect what Medicare will pay?

Medicare pays its share or any Medicare-covered health care service you get iyou don’t take group health plan coverage rom your employer, and you don’thave coverage through an employed spouse.



13Section 2: Medicare & other types of health coverage

Medicare & group health plan coverage (continued)

What happens if I drop coverage from my employer?

Medicare pays first unless you have coverage through an employed spouse, and yourspouse’s employer has at least 20 employees.

Note: I you don’t take employer coverage when it’s first offered to you, you mightnot get another chance to sign up. I you take the coverage but drop it later, youmay not be able to get it back. Also, you might be denied coverage i your employeror your spouse’s employer generally offers retiree coverage but you weren’t in theplan while you or your spouse was still working. Call your employer’s benefitsadministrator or more inormation beore you make a decision.

If I’m 65 or older and still working, what health benefits does my employerhave to offer me?

Generally, employers with 20 or more employees must offer current employees65 and older the same health benefits, under the same conditions, that they offeryounger employees. I the employer offers coverage to spouses, it must offer thesame coverage to spouses 65 and older that it offers to spouses under 65.

Medicare & group health plan coverage after you retire

How does my group health plan coverage work after I retire?

It depends on the terms o your specific plan. Your employer or union or yourspouse’s employer or union might not offer any health coverage afer you retire.I you can get group health plan coverage afer you retire, it might have differentrules and might not work the same way with Medicare.

Can I continue my employer coverage after I retire?

Generally, when you have retiree coverage rom an employer or union, they managethis coverage. Employers aren’t required to provide retiree coverage, and they canchange benefits or premiums, or even cancel coverage.

What are the price and benefits of the retiree coverage, and does it include

coverage for my spouse?

Your employer or union may offer retiree coverage that limits how much it will pay.It might only provide “stop loss” coverage, which starts paying your out-o-pocketcosts only when they reach a maximum amount.

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(continued)

What happens to my retiree coverage when I’m eligible for Medicare?

I your ormer employer offers retiree coverage, the coverage might not pay yourmedical costs during any period in which you were eligible or Medicare but didn’tsign up or it. When you become eligible or Medicare, you may need to joinboth Medicare Part A and Medicare Part B to get ull benefits rom your retireecoverage.

What effect will my continued coverage as a retiree have on both my health

coverage and my spouse’s health coverage?

I you’re not sure how your retiree coverage works with Medicare, get a copy oyour plan’s benefit materials, or look at the summary plan description provided byyour employer or union. You can also call your employer’s benefits administratorand ask how the plan pays when you have Medicare. You may want to talk to yourState Health Insurance Assistance Program (SHIP) or advice about whether tobuy a Medicare Supplement Insurance (Medigap) policy.

How does retiree coverage compare with a Medicare Supplement Insurance

(Medigap) policy?

Since Medicare pays first afer you retire, your retiree coverage is likely to besimilar to coverage under a Medigap policy . Retiree coverage isn’t the same thingas a Medigap policy but, like a Medigap policy, it usually offers benefits that fillin some o Medicare’s gaps in coverage, such as coinsurance and deductibles.Sometimes retiree coverage includes extra benefits, like coverage or extra days inthe hospital.

If I choose to buy a Medigap policy, when should I buy it?

Te best time is during your 6-month Medigap Open Enrollment period, becauseyou can buy any Medigap policy sold in your state, even i you have health

problems. Tis period automatically starts the month you’re 65 and enrolled inPart B, and once it’s over, you can’t get it again.

Remember: You and your spouse would each have to buy your own Medigappolicy, and you can only buy a policy when you’re eligible or Medicare.

For more inormation about Medigap policies, visit Medicare.gov/publications to view the booklet “Choosing a Medigap Policy: A Guide to Health Insurance orPeople with Medicare.” o find and compare Medigap polices, visitMedicare.gov/find-a-plan, or call 1-800-MEDICARE (1-800-633-4227). Y usersshould call 1-877-486-2048.

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(continued)

I’m retired and have Medicare. I also have group health plan coverage from

my own former employer. Who pays first?

Generally, Medicare pays first or your health care bills and your group healthplan (retiree) coverage pays second.

I’m retired and have Medicare. My spouse is still working and I have group

health plan coverage through my spouse’s employer. Who pays first?

I your spouse’s employer has 20 or more employees, your spouse’s coveragepays first and Medicare pays second. I your spouse’s employer has less than 20

employees, Medicare pays first.

What happens if I have group health plan coverage after I retire and my

former employer goes bankrupt or out of business?

I your ormer employer goes bankrupt or out o business, ederal COBRA rulesmay protect you i any other company within the same corporate organizationstill offers a group health plan to its employees. Tat plan is required to offeryou COBRA continuation coverage. See pages 26–27. I you can’t get COBRAcontinuation coverage, you may have the right to buy a Medigap policy even i

you’re no longer in your Medigap Open Enrollment Period.

Medicare & group health plan coverage for people who are

disabled (non-ESRD disability)

I’m under 65, disabled, and have Medicare and group health plan coverage

based on current employment. Who pays first?

It depends. Generally, i your employer has less than 100 employees, Medicarepays first i you’re under 65 or i you have Medicare because o a disability.

Sometimes employers with less than 100 employees join with other employers toorm a multi-employer plan. I at least one employer in the multi-employer planhas 100 employees or more, Medicare pays second.




Medicare & group health plan coverage for people who are

disabled (non-ESRD disability) (continued)

I’m under age 65, disabled, and have Medicare and group health plancoverage based on current employment. Who pays first? (continued)

I the employer has at least 100 employees, the health plan is called a large grouphealth plan. I you’re covered by a large group health plan because o your currentemployment or the current employment o a amily member (including, but notlimited to a spouse, a domestic partner, son, daughter, or grandchild), Medicarepays second. A large group health plan can’t treat any plan member differentlybecause they’re disabled and have Medicare.

Example: Mary works ull-time or a company that has 120 employees. She has largegroup health plan coverage or hersel and her husband. Her husband has Medicarebecause o a disability, so Mary’s group health plan coverage pays first or Mary’shusband, and Medicare pays second.

Medicare & group health plan coverage for people with

End-Stage Renal Disease (ESRD)

I have ESRD and group health plan coverage. Who pays first?

I you’re eligible or Medicare because o ESRD, your group health plan will pay firston your hospital and medical bills or 30 months, whether or not you’re in Medicare.During this time, Medicare pays second.

Te group health plan pays first during this period no matter how many employeeswork or your employer, or whether you or a amily member are currentlyemployed. At the end o the 30 months, Medicare pays first. Tis rule applies tomost people with ESRD, whether you have your own group health plan coverage, oryou’re covered as a amily member.

Example: Bill has Medicare coverage because o ESRD. He also has group healthplan coverage through his company. Bill’s group health plan coverage will pay firstor the first 30 months afer he becomes eligible or Medicare. Afer 30 months,Medicare pays first.




Medicare & no-fault or liability insurance

What’s no-fault insurance?

No-ault insurance may pay or health care services you get because you get injuredor your property gets damaged in an accident, regardless o who is at ault orcausing the accident.

Some types o no-ault insurance include:

• Automobile insurance

• Homeowners’ insurance

• Commercial insurance plans

What’s liability insurance?Liability insurance protects against claims or negligence— or example,inappropriate action or inaction that causes someone to get injured or causesproperty damage.

Some types o liability insurance include:

• Homeowners’

• Automobile

• Product

• Malpractice• Uninsured motorist

• Underinsured motorist

I you have an insurance claim or your medical expenses, you or your lawyershould notiy Medicare as soon as possible.

Who pays first if I have a claim for no-fault or liability insurance?

No-ault insurance or liability insurance pays first and Medicare pays second, i

appropriate.I doctors or other providers are told you have a no-ault or liability insurance claim,they must try to get paid rom the insurance company beore billing Medicare.However, this may take a long time. I the insurance company doesn’t pay theclaim promptly (usually within 120 days), your doctor or other provider may billMedicare. Medicare may make a conditional payment to pay the bill, and then laterget back any payments the primary payer should have made.




Medicare & no-fault or liability insurance (continued)

Who pays first if I have a claim for no-fault or liability insurance? (continued)

Example: Nancy is 69 years old. She’s a passenger in her granddaughter’s car, andthey have an accident. Nancy’s granddaughter has Personal Injury Protection/Medical Payments (Med Pay) coverage as part o her automobile insurance. Whileat the hospital emergency room, Nancy is asked about available coverage related tothe accident. Nancy tells the hospital that her granddaughter has Med Pay coverage.Because this coverage pays regardless o ault, it’s considered no-ault insurance. Tehospital bills the no-ault insurance or the emergency room services, and only billsMedicare i any Medicare-covered services aren’t paid or by the no-ault insurance.

What’s a conditional payment?

A conditional payment is a payment Medicare makes or services another payer maybe responsible or. Medicare makes this conditional payment so you won’t have touse your own money to pay the bill. Te payment is “conditional” because it must berepaid to Medicare when a settlement, judgment, award, or other payment is made.

Note: I Medicare makes a conditional payment or an item or service, and youget a settlement, judgment, award, or other payment or that item or service rom

an insurance company later, the conditional payment must be repaid to Medicare.You’re responsible or making sure Medicare gets repaid or the conditionalpayment.

Example: Joan is driving her car when someone in another car hits her. Joan hasto go to the hospital. Te hospital tries to bill the other driver’s liability insurer.Te insurance company disputes who was at ault and won’t pay the claim rightaway. Te hospital bills Medicare, and Medicare makes a conditional payment tothe hospital or health care services Joan got. When a settlement is reached withthe liability insurer, Joan must make sure Medicare gets its money back or the

conditional payment.




Medicare & no-fault or liability insurance (continued)

How does Medicare get its money back for the conditional payment?

I Medicare makes a conditional payment, you or your representative should callthe Benefits Coordination & Recovery Center (BCRC) toll-ree at 1-855-798-2627.Y users should call 1-855-797-2627. Te BCRC will work on your case, using theinormation you or your representative gives it to see that Medicare gets repaid orthe conditional payments.

Te BCRC will gather inormation about any conditional payments Medicare maderelated to your pending settlement, judgment, award, or other payment. Once asettlement, judgment, award, or other payment is final, you or your representativeshould call the BCRC. Te BCRC will get the final repayment amount (i any) on

your case and issue a letter requesting repayment.

Who pays if the no-fault or liability insurance denies my medical bill or is

found not liable for payment?

Medicare would pay or covered services, unless you have group health plan coverage that must pay beore Medicare. You’re responsible or your share o thebill, like coinsurance, copayment, or a deductible, and or services Medicare doesn’tcover.

Where can I get more information?

I you have questions about a no-ault or liability insurance claim, call the insurancecompany. I you have questions about who pays first, call the BCRC.

Medicare & workers’ compensation

What’s workers’ compensation?

Workers’ compensation is a law or plan requiring employers to cover employeeswho get sick or injured on the job. Workers’ compensation plans cover mostemployees. I you don’t know whether you’re covered, ask your employer, or contact

your state workers’ compensation division or department.

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Medicare & workers’ compensation (continued)

I have Medicare and filed a workers’ compensation claim. Who pays first?

I you have Medicare and get injured on the job, workers’ compensation pays first onhealth care items or services you got because o your work-related illness or injury.Tere can be a delay between when a bill is filed or the work-related illness orinjury and when the state workers’ compensation insurance decides i they shouldpay the bill. Medicare can’t pay or items or services that workers’ compensation willpay or promptly (generally 120 days).

However, i the workers’ compensation insurer denies payment or your medicalbills pending a review o your claim (generally 120 days or longer), Medicare maymake a conditional payment. Tis isn’t the same situation as when your workers’

compensation case has been settled and you’re using unds rom your Workers’Compensation Medicare Set-aside Arrangement (WCMSA) to pay or your medicalcare. See next page or more inormation on WCMSAs.

If you think you have a work-related illness or injury, tell your employer, and

file a workers’ compensation claim.

You or your lawyer also need to call the BCRC toll-ree at 1-855-798-2627 as soon asyou file your workers’ compensation claim. Y users should call 1-855-797-2627.

Example: om was injured at work. He filed a claim with workers’ compensationinsurance. His doctor billed the state workers’ compensation insurance or payment.om’s doctor didn’t get paid within 120 days, so he billed Medicare and sent acopy o om’s workers’ compensation claim with the claim or Medicare payment.Medicare made a conditional payment to the doctor or the health care services omgot. When a settlement is reached with the state workers’ compensation agency,om must make sure Medicare gets its money back or the conditional payment.

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How does Medicare get its money back for the conditional payment?

I Medicare makes a conditional payment, and you or your lawyer haven’t reportedyour worker’s compensation claim to Medicare, call the Benefits Coordination& Recovery Center (BCRC) toll-ree at 1-855-798-2627. Y users should call1-855-797-2627. Te BCRC will work on your case, using the inormation youor your representative gives it to see that Medicare gets repaid or the conditionalpayments.

Te BCRC will gather inormation about any conditional payments Medicare maderelating to your pending settlement, judgment, award or other payment. Once asettlement, judgment, award or other payment is final, you or your lawyer should

call the BCRC. Te BCRC will get the final repayment amount (i any) on your caseand issue a letter requesting repayment.

What if I want to settle my workers’ compensation claim?

You or your lawyer should contact the BCRC. Settlements o workers’ compensationclaims are handled differently than a settlement o a no-ault or liability insuranceclaim. As part o settling your workers’ compensation claim, you must repayMedicare or any Medicare payments or workers’ compensation claim-relatedservices you already got.

When and why would I need a Workers’ Compensation Medicare Set-aside

Arrangement (WCMSA)?

I you settle your worker’s compensation claim, the settlement may provide or undsto be set aside to pay or uture medical and prescription drug expenses related to yourinjury, illness or disease. When you have Medicare, you may wish to ask your workers’compensation lawyer about the possibility o setting up a Workers’ CompensationMedicare Set-aside Arrangement (WCMSA) or depositing these unds.

Te WCMSA ensures workers’ compensation unds are spent on these utureexpenses otherwise covered by Medicare. In other words, workers’ compensation

pays beore Medicare or these uture expenses. I you have a WCMSA as part oyour workers’ compensation settlement, you must be careul how you spend moneyspecifically set aside or Medicare.

You or your lawyer need to send your proposed WCMSA to the BCRC at:

WCMSA Proposal/Final Settlement

P.O. Box 138899

Oklahoma City, OK 73113-8899

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How am I allowed to use the money in my Workers’ Compensation Medicare

Set-aside Arrangement (WCMSA) if I manage (self-administer) the account?

Keep these in mind i you manage your WCMSA account:

• Money placed in your WCMSA is or paying uture medical expenses, includingprescription drug expenses related to your work injury or illness/disease thatotherwise would have been paid back by Medicare. You should also use WCMSAunds to pay or these medical services and items, as well as prescription drugexpenses, i you’re enrolled in a Medicare Advantage Plan.

• You can’t use the WCMSA to pay or any other work injury, or any medical itemsor services that Medicare doesn’t cover (like dental services).

• Medicare won’t pay or any medical expenses related to the injury until afer youhave used all o your set-aside money appropriately.

• I you aren’t sure what type o services Medicare covers, visit Medicare.gov or call1-800-MEDICARE (1-800-633-4227) or more inormation, beore you use anyo the money that was placed in your WCMSA account. Y users should call1-877-486-2048.

• Keep records o your workers’ compensation-related medical expenses, includingprescription drug expenses. Tese records show what items and services you gotand how much money you spent on your work-related injury, illness, or disease.You need these records to prove you used your WCMSA money to pay yourworkers’ compensation-related medical expenses, including prescription drugexpenses.

• Afer you use all o your WCMSA money appropriately, Medicare can start payingor Medicare-covered services related to your work-related injury, illness, ordisease.

What if workers’ compensation denies payment?

I workers’ compensation insurance denies payment, and you give Medicare proo

that the claim was denied, Medicare will pay or Medicare-covered items andservices as appropriate.

Example: Mike was injured at work. He filed a workers’ compensation claim.Te workers’ compensation agency denied payment or Mike’s medical bills. Mike’sdoctor billed Medicare and sent Medicare a copy o the workers’ compensationdenial with the claim or Medicare payment. Medicare will pay Mike’s doctor or theMedicare-covered items and services Mike got as part o his treatment. Mike mustpay or anything Medicare doesn’t cover.


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Can workers’ compensation decide not to pay my entire bill?

In some cases, workers’ compensation insurance may not pay your entire bill.I you had an injury or illness beore you started your job (called a “pre-existingcondition”), and the job made it worse, workers’ compensation may not pay yourwhole bill because the job didn’t cause the original problem. In this case, workers’compensation insurance may agree to pay only a part o your doctor or hospitalbills. You and workers’ compensation insurance may agree to share the cost o yourbill. I Medicare covers the treatment or your pre-existing condition, then Medicaremay pay its share or part o the doctor or hospital bills that workers’ compensationdoesn’t cover.

Medicare & Veterans’ benefits

I have Medicare and Veterans’ benefits. Who pays first?

I you have or can get both Medicare and Veterans’ benefits, you can get treatmentunder either program. When you get health care, you must choose which benefitsto use each time you see a doctor or get health care. Medicare can’t pay or the sameservice that was covered by Veterans’ benefits, and your Veterans’ benefits can’tpay or the same service that was covered by Medicare. Also, Medicare is never thesecondary payer afer the Department o Veterans Affairs (VA). Note: to get the VA

to pay or services, you must go to a VA acility or have the VA authorize services ina non-VA acility.

Are there any situations when both Medicare and the VA may pay?

Yes. I the VA authorizes services in a non-VA hospital, but didn’t authorize all o theservices you get during your hospital stay, then Medicare may pay or the Medicare-covered services the VA didn’t authorize.

Example: Bob, a Veteran, goes to a non-VA hospital or a service authorized by

the VA. While at the non-VA hospital, Bob gets other non-VA authorized servicesthat the VA won’t pay or. Some o these services are Medicare-covered services.Medicare may pay or some o the non-VA authorized services that Bob got. Bobwill have to pay or services that Medicare or the VA doesn’t cover.

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Medicare & Veterans’ benefits (continued)

I have a VA fee-basis identification (ID) card. Who pays first?

Te VA may give “ee-basis ID cards” to certain Veterans i these conditions apply:

• You have a service-connected disability.

• You’ll need medical services or an extended time period.

• Tere are no VA hospitals in your area.

I you have a ee-basis ID card, you may choose any doctor listed on your card totreat you.

I the doctor accepts you as a patient and bills the VA or services, the doctor must

accept the VA’s payment as payment in ull. Te doctor can’t bill you or Medicare orthese services.

I your doctor doesn’t accept the ee-basis ID card, you’ll need to file a claim withthe VA yoursel. Te VA will pay the approved amount either to you or to yourdoctor.

Where can I get more information on Veterans’ benefits?

Visit VA.gov , call your local VA office, or call the national VA inormation numberat 1-800-827-1000. Y users should call 1-800-829-4833.

Medicare & TRICARE

What’s TRICARE?

RICARE is a health care program or active-duty and retired uniormed servicesmembers and their amilies that includes:

• RICARE Prime.

• RICARE Extra.

• RICARE Standard.

• RICARE or Lie (FL). FL provides expanded medical coverage toMedicare-eligible uniormed services retirees 65 or older, to their eligible amily

members and survivors, and to certain ormer spouses. You must have MedicarePart A (Hospital Insurance) and Medicare Part B (Medical Insurance) to get FLbenefits.

http://www.va.gov/

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Medicare & Veterans’ benefits (continued)

Can I have both Medicare and TRICARE?

Some people can have both Medicare and other types o RICARE, including:

• Dependents o active-duty service members who are allowed Medicare or anyreason.

• People under 65 with Medicare Part A (Hospital Insurance) because o adisability or End-Stage Renal Disease (ESRD) and with Medicare Part B (MedicalInsurance).

• People 65 or older who can get Part A and who join Part B.

I have Medicare and TRICARE. Who pays first?In general, Medicare pays first or Medicare-covered services. RICARE will paythe Medicare deductible and coinsurance amounts and or any service not coveredby Medicare that RICARE covers. You pay the costs o services Medicare orRICARE doesn’t cover.

Who pays if I get services from a military hospital?

I you get services rom a military hospital or any other ederal health care provider,RICARE will pay the bills. Medicare usually doesn’t pay or services you get rom aederal health care provider or other ederal agency.


• Visit ricare.mil/tfl.

• Call the health benefits advisor at a military hospital or clinic.

• Call 1-866-773-0404.

http://www.tricare.mil/

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Medicare & the Federal Black Lung Benefits Program

I have Medicare and coverage under the Federal Black Lung Benefits Program.

Who pays first?

Te Federal Black Lung Benefits Program pays first or any health care or blacklung disease covered under that program. Medicare won’t pay or doctor or hospitalservices covered under the Federal Black Lung Benefits Program. Your doctor orother health care provider should send all bills or the diagnosis or treatment oblack lung disease to:

Federal Black Lung ProgramP.O. Box 8302London, Kentucky 40742-8302

For all other health care not related to black lung disease, Medicare pays first, andyour doctor or health care provider should send your bills directly to Medicare.

What if the Federal Black Lung Benefits Program won’t pay my bill?

Ask your doctor or other health care provider to send Medicare the bill. Ask them toinclude a copy o the letter rom the Federal Black Lung Benefits Program that sayswhy it won’t pay your bill.


Call 1-800-638-7072 i you have questions about the Federal Black Lung BenefitsProgram. I you have questions about who pays first, call the Benefits Coordination& Recovery Center (BCRC) toll-ree at 1-855-798-2627. Y users should call1-855-797-2627.

Medicare & COBRA

What’s COBRA?

COBRA is a ederal law that may allow you to temporarily keep employer or unionhealth coverage afer the employment ends or afer you lose coverage as a dependent

o the covered employee. Tis is called “continuation coverage.”

In general, COBRA only applies to employers with 20 or more employees. However,some state laws require insurers covering employers with ewer than 20 employeesto let you keep your coverage or a period o time.

In most situations that give you COBRA rights (other than a divorce), you shouldget a notice rom your employer’s benefits administrator or the group health plantelling you your coverage is ending and offering you the right to elect COBRAcontinuation coverage.

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Medicare & COBRA (continued)

Tis coverage generally is offered or 18 months (or 36 months, in some cases).I you don’t get a notice, but you find out your coverage has ended, or i you getdivorced, call the employer’s benefits administrator or the group health plan as soonas possible and ask about your COBRA rights.

I you qualiy or COBRA because the covered employee either died, lost his/her job,or can now get Medicare, then the employer must tell the plan administrator. Oncethe plan administer is notified, the plan must let you know you have the right tochoose COBRA coverage.

However, i you qualiy or COBRA because you’ve become divorced or legallyseparated (court issued separation decree) rom the covered employee, or i youwere a dependent child or dependent adult child who is no longer a dependent, thenyou or the covered employee needs to let the plan administrator know about yourchange in situation within 60 days o the change happening.

I have Medicare and COBRA continuation coverage. Who pays first?

In general, the rules described on pages 12–15 that apply to group health plancoverage also apply to COBRA continuation coverage. For example, i you or yourspouse are 65 or over, retired, and have COBRA continuation coverage, Medicarepays first.

I you have Medicare based on End-Stage Renal Disease (ESRD), COBRAcontinuation coverage pays first. Medicare pays second to the extent COBRA coverageoverlaps the first 30 months o Medicare eligibility or entitlement based on ESRD.

Whether and when you should elect COBRA coverage can be a very complicateddecision. When you lose employer coverage and you have Medicare, you need tobe aware o your COBRA election period, your Part B enrollment period, and yourMedigap Open Enrollment Period. Tese may all have different deadlines thatoverlap, so be aware that what you decide about one type o coverage (COBRA,Part B, and Medigap) might cause you to lose rights under one o the other types o

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Medicare & COBRA (continued)

Where can I get more information about COBRA?

• Beore you elect COBRA coverage, you can talk with your State Health InsuranceAssistance Program (SHIP) about Medicare Part B (Medical Insurance) andMedicare Supplementary (Medigap) Insurance. Visit Medicare.gov/contacts, orcall 1-800-MEDICARE (1-800-633-4227) to get the phone number. Y usersshould call 1-877-486-2048.

• Call your employer’s benefits administrator or questions about your specificCOBRA options.

• I you have questions about Medicare and COBRA, call the Benefits Coordination

& Recovery Center (BCRC) toll-ree at 1-855-798-2627. Y users should call1-855-797-2627.

• I your group health plan coverage was rom a private employer (not agovernment employer), visit the Department o Labor at dol.gov , or call1-866-444-3272.

• I your group health plan coverage was rom a state or local government employer,call the Centers or Medicare & Medicaid Services (CMS) at 1-877-267-2323,extension 61565.

• I your coverage was with the ederal government, visit the Office o PersonnelManagement at opm.gov .

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29

SECTION

Definitions

3 Benefits Coordination & Recovery Center (BCRC)—Tecompany that acts on behal o Medicare to collect and manageinormation on other types o insurance or coverage that aperson with Medicare may have, and determine whether thecoverage pays beore or afer Medicare. Tis company also actson behal o Medicare to obtain repayment when Medicaremakes a conditional payment, and the other payer is determinedto be primary.

Claim—A request or payment that you submit to Medicare orother health insurance when you receive items and services thatyou think are covered.

Coinsurance—An amount you may be required to pay as yourshare o the cost or services, afer you pay any deductibles.Coinsurance is usually a percentage (or example, 20%).

Copayment—An amount you may be required to pay asyour share o the cost or a medical service or supply, like adoctor’s visit, hospital outpatient visit, or a prescription drug.A copayment is usually a set amount, rather than a percentage.For example, you might pay $10 or $20 or a doctor’s visit or

prescription.

Deductible—Te amount you must pay or health care orprescriptions, beore Original Medicare, your prescription drugplan, or your other insurance begins to pay.

End-Stage Renal Disease (ESRD)—Permanent kidney ailurethat requires a regular course o dialysis or a kidney transplant.

Group health plan—In general, a health plan offered by anemployer or employee organization that provides health coverageto employees, ormer employees, and their amilies.

Where words in purple are defined



30 Section 3: Definitions

Health care provider —A person or organizationthat’s licensed to give health care. Doctors,nurses, and hospitals are examples o health careproviders.

Large group health plan—In general, a grouphealth plan that covers employees o either anemployer or employee organization that has at least100 employees.

Medicaid—A joint ederal and state program thathelps with medical costs or some people withlimited income and resources. Medicaid programs

vary rom state to state, but most health care costsare covered i you qualiy or both Medicare and

Medicaid.

Medicare Part A (Hospital Insurance)—Coverage or inpatient hospital stays, care in askilled nursing acility, hospice care, and somehome health care.

Medicare Part B (Medical Insurance)—Coverageor certain doctors’ services, outpatient care,medical supplies, and preventive services.

Medicare Advantage Plan (Part C)—A typeo Medicare health plan offered by a privatecompany that contracts with Medicare to provideyou with all your Medicare Part A and Part Bbenefits. Medicare Advantage Plans include HealthMaintenance Organizations, Preerred ProviderOrganizations, Private Fee-or-Service Plans,Special Needs Plans, and Medicare Medical SavingsAccount Plans. I you’re enrolled in a MedicareAdvantage Plan, Medicare services are covered

through the plan and aren’t paid or under OriginalMedicare. Most Medicare Advantage Plans offerprescription drug coverage.

Medicare prescription drug plan

(Part D)—A stand-alone drug plan that addsprescription drug coverage to Original Medicare,some Medicare Cost Plans, some MedicarePrivate-Fee-or-Service Plans, and MedicareMedical Savings Account Plans. Tese plans areoffered by insurance companies and other privatecompanies approved by Medicare. MedicareAdvantage Plans may also offer prescription drugcoverage that ollows the same rules as MedicarePrescription Drug Plans.

Medigap policy —Medicare Supplement Insurance

sold by private insurance companies to ill “gaps” in

Original Medicare coverage.

Multi-employer plan—In general, a group

health plan that’s sponsored jointly by 2 or more

employers.

Premium—he periodic payment to Medicare, an

insurance company, or a health care plan or health

or prescription drug coverage.

State Health Insurance Assistance Program

(SHIP)—A state program that gets money romthe ederal government to give ree local health

insurance counseling to people with Medicare.

TTY—A Y (teletypewriter) is a communication

device used by people who are dea, hard-o-

hearing, or have a severe speech impairment. People

who don’t have a Y can communicate with a

Y user through a message relay center (MRC).

An MRC has Y operators available to send and

interpret Y messages.Workers’ compensation—A plan that employers

are required to have to cover employees who get

sick or injured on the job.



31

SECTION

Index

4 An alphabetical list of what’s in this guide

1-800-MEDICARE 11, 14, 22, 24, 26

AAccident 7, 17

BBeneits Coordination & Recovery Center

(BCRC) 5, 8, 9, 19–21, 26–28, 29Black lung disease 7, 26

CClaim 7, 8, 17–22, 24, 29

COBRA 6, 7, 15, 26–28 Coinsurance 14, 19, 25, 29 Conditional payment 7, 17–21 Copayment 19, 29

DDeductible 14, 19, 25, 29 Denial o payment 22

Disabled 6, 7, 15–16

E

End-Stage Renal Disease 6, 16, 25, 27, 29F Federal Black Lung Program 7, 26

GGroup health plan 6, 8, 11–16, 19, 26–28, 29



32 Section 4: Index

HHealth care provider 2, 5, 7, 8, 12, 17, 25, 26, 30

IInitial Enrollment Questionnaire 8

LLarge group health plan 6, 15–16

Liability Insurance 7, 17–19

MMedicaid 6, 11, 30

Medicare Part A (Hospital Insurance) 5, 14, 24, 25, 30 Medicare Part B (Medical Insurance) 5, 11, 14, 24, 25, 27, 28, 30

Medicare prescription drug coverage (Part D) 11, 21, 22, 30 Medicare secondary payer 5, 12, 23 Medigap 11, 14, 15, 27, 28, 30

Multi-employer plan 12, 15, 30

N No-ault insurance 7, 17–19

P Pre-existing condition 23

Premium 13, 30

Primary payer 5, 17R Retiree coverage 6, 11, 13–15

S State Health Insurance Assistance Program (SHIP) 11, 14, 28, 30

T RICARE 7, 24–25

RICARE or Lie (FL) 24

V

Veterans’ beneits 7, 23–25WWorkers’ compensation 7, 19–23

Workers’ Compensation Medicare Set-aside Arrangement(WCMSA) 20–22



U.S. DEPARTMENT OFHEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security BoulevardBaltimore, Maryland 21244-1850

Oicial BusinessPenalty or Private Use, $300

CMS Product No. 02179Revised April 2014

■ Medicare.gov

■ 1-800-MEDICARE (1-800-633-4227)

■ Y: 1-877-486-2048

cob who pay first

Documents