Medicare COB – Basics
It’s important to know how Medicare works with other kinds of health or drug coverage and who should pay your bills first. This is called “coordination of benefits.”
If you have Medicare and other health or drug coverage, each type of coverage is called a “payer.” When there’s more than one potential payer, there are coordination rules to decide who pays first. The first or “primary payer” pays what it owes on your bills, and then sends the remainder of the bill to the second or “secondary payer.” In some cases, there may also be a third payer.
Tell your doctor, hospital, and all other health care providers about all of your health or drug coverage to make sure your bills are sent to the right payers, in the right order.
Whether Medicare pays first depends on a number of things, including the situations listed in the chart on the next page. However, this chart doesn’t cover every situation.
Recognize When COB Is Needed
There are many different scenarios that require COB. For example:
• If both spouses in a married couple are each covered by their own group (through their employer) or individual coverage (through an independent insurer or Healthcare.org), each policy where the patient is the primary policyholder would be the primary payer.
• If one spouse elects to add the other spouse to their policy as a dependent, then that coverage would be secondary. (Check your plan for rules on domestic partner coverage.)
• If a married couple has children, the insurance of the parent whose birthday (month/date) falls first in the calendar year would be primary. This is called the “birthday rule.” The other parent’s coverage would be secondary. Should the parents have the same birthday (month/day), then the policy with the longest effective date would be considered primary.
With the implementation of the Affordable Care Act (ACA), parents can cover their dependents on their insurance plans until the age of 26, regardless of the dependent’s student or marital status
COB in Patients With Medicare
Patients covered by Medicare due to retirement, disability or end-stage renal disease (ESRD) have their own detailed COB rules. When a patient retires but continues to be covered by an employer group plan, Medicare is the primary payer and the retirement group coverage is secondary.
If the retired individual is working or the patient is covered by a working spouse, and insurance benefits are provided by their employer who has more than 20 employees, then the employer’s group plan is primary and Medicare is secondary. If the employer has less than 20 employees, Medicare is considered primary.Prevent CO-22 Claim DenialsFollow COB rules to determine when care may be covered by another payer.
For a patient covered by Medicare due to a disability and also covered (or eligible for coverage through a family member) by an employer plan (who employs 100 or more employees), the employer’s plan is primary and Medicare is secondary — unless there are fewer than 100 employees, which would make Medicare primary.
In cases where an employee or family member has ESRD and employer coverage, regardless of employer size, the group plan must cover the initial 30 months after coverage eligibility. Medicare then pays first after this period.
Other Circumstances for COB
Claims for work-related injuries or illnesses should be sent to the reported workers’ compensation program, which covers care directly associated with the job-related injury. If workers’ compen-sation does not make a decision regarding claim payment within 120 days, then the claim can be submitted to Medicare, which
may make a conditional payment.
However, when the workers’ compensation claim is paid or settled, Medicare or the other payer must be paid back.Injuries acquired during an auto accident may be required to be sent to an auto personal injury protection (PIP) policy first before submitting claims to a healthcare payer, depending on state laws and options.
When a patient is covered by Medicare or a commercial payer and Medicaid, then Medicaid is the payer of last resort. Providers must first exhaust all other sources of payment — Medicare, Tricare, com-mercial insurance, supplemental plans, workers’ compensation, and PIP coverage. Some state Medicaid programs will pay providers who can submit documentation showing that they have attempted to bill the other sources of payment but were unsuccessful after a specified period of time. These Medicaid programs have a third-party liability department that will continue to attempt to recover the payment from the other payment sources
Which insurance would pays first
If you have retiree insurance (insurance from former employment)… Medicare pays first.
If you’re 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has 20 or more employees… Your group health plan
pays first.
If you’re 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has fewer than 20 employees… Medicare pays first.
If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has 100 or more employees… Your group health plan pays first.
If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has fewer than 100 employees…
Medicare pays first.
If you have group health plan coverage based on your or a family member’s current employment, and you’re eligible for Medicare because of End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)… Your group health plan will pay first for the first 30 months after you become eligible to join Medicare. Medicare will pay first after this 30-month period
Why is COB important?
Medicare may have the incorrect coordination of benefits filing order for you.
If you have Medicare and other health insurance or coverage, each type of coverage is called a “payer.” When there is more thanone source of coverage, “coordination of benefits” rules decide which one pays first. The “primary payer” pays what it owed onyour charges first, and then sends the rest to the “secondary payer” to pay. The insurance that pays first is called the primary payer.The primary payer pays up to the limits of its coverage. The insurance that pays second is called the secondary or supplemental payer. The secondary or supplemental payer only pays if there are costs the primary insurer did not cover.
The Medicare COB program wants to make sure Medicare pays your claims right the first time, every time. The Benefits Coordination & Recovery Center (BCRC) collects information on your health care coverage and stores it in your Medicare record. This record must be updated every time you make a change to your health care coverage.
When do I update my COB?
We depend upon your help for us to bill for your health care services correctly. To streamline claim processing and reduce the number of denials of payment related to coordination of benefits, you must contact the BCRC about any changes in your health insurance due to you, your spouse, or a family member’s current employment or coverage changes. It is also important to confirm your existing coordination of benefits information or update it when your plan renews each year. You must also contact the other insurance plan and confirm the filing order as primacy or secondary.
How do I update my COB?
It is very important that your COB information is updated and accurate before your next visit. Call the Medicare BCRC at thephone number below to update your insurance coordination of benefits information.
Benefits Coordination & Recovery Center (BCRC) Customer Service Representatives are available to assist you Monday through Friday, from 8 am to 8 pm, Eastern Time, except holidays, at toll-free lines: 1-855-798-2627 (TTY/TDD: 1-855-797-2627 for the hearing and speech impaired).
Remember these important facts
• The insurance that pays first (primary payer) pays up to the limits of its coverage.
• The one that pays second (secondary payer) only pays if there are costs the first payer didn’t cover.
• The secondary payer (which could be Medicare) might not pay all of the uncovered costs.
• If Medicare is the primary payer and your employer is the secondary payer, you’ll need to join Medicare Part B (Medical Insurance) before your employer insurance will pay for Part B
services.
These types of insurance usually pay first for services related to each type:
• No-fault insurance (including automobile insurance)
• Liability (including self-insurance plans and automobile insurance)
• Black lung benefits
• Workers’ compensation
Medicaid and TRICARE never pay first for services that Medicare covers. They only pay after Medicare, employer group health plans, and/or Medicare Supplement Insurance (Medigap)
have paid.
If you still have questions about who should pay or who should pay first:
• Check your insurance policy or coverage. It may include rules about who pays first.
• Call the Benefits Coordination & Recovery Center (BCRC) at
1-855-798-2627. TTY users can call 1-855-797-2627.
• Contact your employer or union benefits administrator
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