Who will pay first?

Published 12:00 am Saturday, December 25, 2021

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

I have just started following your Medicare column in our local paper and am finding you are answering problems, I never knew I could have. Thank You so much.

Roxanne, Pacific Palisades, CA



Let’s start with discussing enrolling in Medicare Part B when working with an employer group health plan.  The Medicare & You handbook discusses “Should 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 that employer or union, contact your employer or union benefits administrator to find out how your coverage works with Medicare… It might be to your advantage to delay Part B enrollment.”

To answer about enrolling in Medicare Part B, it is optional because when you leave your or your spouse’s employer group health plan, then you can enroll in Medicare Part B with a Special Enrollment Period.

Now let’s talk about who will pay your claim first and this depends on how many employees are on your company’s group health plan:

  • Your employer has 20 or more employees. Your group health plan will generally be primary. Should your group health plan not pay all the bill, you may need to ask the health care provider or your doctor to send the remainder of the bill to Medicare if you are enrolled in Medicare Parts A and/or B for secondary payment. Should there be any cost your health insurance or Medicare did not cover, you will have to pay the balance.

 The employer must offer their employees 65 and older the same health benefits, under the same conditions, they offer employees under 65.

  • Your employer has less than 20 employees. Medicare pays first. Discuss with your employer’s HR department or employer group health insurance agent as to whether to enroll in Medicare Parts A and/or B since a small amount of health insurance plans require employees employed by companies with group health plans that cover 20 employees or less to enroll in Medicare Part B. CMS form L-564 “Request for Employer Information” is available for employees “still working” past 65 with true employer insurance to avoid Medicare’s Part B penalty. This form is available for the employee and their spouse enrolling in Medicare Part B past 65 years old. *Remember that the six-month Medicare Medigap/Supplement Enrollment period begins when one is first enrolled in Medicare Part B*
  • Your employer has less than 20 employees. The small employer joins forces with other employers or employer organizations i.e., unions, to sponsor a multi-employer plan (group health plan). Sometimes employers with less than 100 employees will band together to form a multi-employer plan. Medicare pays second.

Always check with your Human Resources to find out if the Insurance Company will pay first when the employees or employees’ spouses are over 65 and on company health benefits.

  • One thing to know is that if you should go outside your employer’s network, it is possible that neither the company’s plan nor Medicare will pay.

For a Medicare Checkup, call the Toni Says® Medicare call center at 832/519-8664 or email info@tonisays.com regarding your Medicare plans and options. Toni Says® Medicare Survival Guide is available at www.tonisays.com.