Medicare and Employer Coverage
There are a couple of questions that often come up when discussing Medicare. For one, can you have Medicare and your employer’s health insurance plan at the same time? And two, if one can have both, then how would they work together?
Can I have Medicare and still be covered under my employer’s health insurance plan?
Yes, you can, and people often have both. However, you should check with your employer’s group health plan first, just in case your employer coverage conflicts with Medicare.
How do Medicare and employer health insurance work together?
When you have both Medicare and employer health insurance, the two become known as “payers.” This is in reference to the order in which they pay, which then influences the amount each one covers.
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When would employer health insurance pay first?
Oftentimes, the employer’s health insurance plan is the first payer. Your employer’s health plan will pay as much as it can for your medical expenses, and then Medicare will come in and pay what it can for the rest.
Employer health insurance pays first in these situations:
- The employer providing the health insurance has 20 or more employees. This also applies if your coverage is from your spouse’s employer health insurance plan.
- If an employer has fewer than 20 employees, the employer’s health insurance can pay first if that employer is part of another employer or employee organization (a union, for instance). Another case is when there is another employer who has at least 20 employees. But it’s very important to check with your policy about this, because there is no guaranteed order of who the first payer will be.
- If you’re under 65, disabled, retired, and the coverage comes from a family member who is covered under his or her employer’s health insurance plan. However, that’s if your family member’s employer has at least 100 employees.
- For those who have End-Stage Renal Disease (ESRD), there will be a coordination period that could last up to 30 months. The employer’s health insurance plan will pay first during this period. Medicare will become the first payer after the consolidation period is over.
When does Medicare pay first?
Medicare usually doesn’t pay first, but there are exceptions. Medicare will be the first payer in situations such as:
- Your employer has fewer than 20 employees. The same goes if you’re covered under your spouse who gets health insurance through his or her employer (who has fewer than 20 employees).
- When your employer’s health insurance doesn’t pay a claim within 120 days. Medicare will pay first, but this is usually in the form of a conditional payment. Medicare pays what should be covered by your employer’s health insurance, with the expectation that the employer’s health insurance plan repays Medicare for what should’ve been covered.
- If you have End-Stage Renal Disease (ESRD) and are receiving health insurance through your employer. Medicare becomes the first payer once the coordination period ends. This period lasts up to 30 months.
- If you’re under 65, disabled, and receiving health insurance from your former employer, then Medicare will pay first.
What could disqualify one from getting coverage?
In general, it’s best to speak to your insurer before adding Medicare. The answer is typically in the form of which will pay first. But sometimes, this could be a matter between having extra coverage and losing a policy.
You should also be aware of how a healthcare provider works with your insurance. This is especially the case if you are on a Health Maintenance Organization (HMO) or your employer’s Preferred Provider Organization (PPO) plan. These types of plans often have a narrower coverage network, so your choices in where you get treatment are limited. In other words, If that hospital or other treatment facility doesn’t accept your policy, then it’s out of network. And when that happens, your employer’s health insurance won’t cover the costs, and Medicare may not cover you, either.
Contacting your provider is a must if you’re considering Medicare Advantage. In some cases, joining Medicare Advantage may result in being dropped by your employer’s health insurance plan. And when it’s dropped, you may not be able to get it back.
Call us at 281-639-7787 or send an email to [email protected] for any questions or concerns you may have regarding Medicare and employer coverage.
