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Medicare and Other Insurance Coverage

What if a client has more than one type of insurance or coverage, as well as Medicare?

A client may have more than one type of insurance or coverage that will pay for services and procedures before, or along with, Medicare. If the client has a question about who should pay, or who should pay first, instruct the client to check their insurance policy or coverage. It may include a coordination of benefits clause. After January 1, 2002, the client should call the Medicare Coordination of Benefits Contractor at 800/999-1118 with questions about Medicare, who pays first, or how the client's coverage works with Medicare.

The following chart lists common types of coverage that clients may have and describes how other insurance interface with Medicare (additional insurance information will be posted on ADA's Web site). As a provider, RDs billing Medicare Part B for diabetes and renal MNT have a responsibility to understand which insurance plan pays first for MNT services, and the responsibility to help educate their clients on Medicare rules. As with all provider and beneficiary information this is subject to change and the client should always verify the current policy and procedures with Centers for Medicare and Medicaid Services (CMS) source documents.

Medicare and Group Health Coverage
The client is 65, has Medicare, and is covered by a group health plan because of current employment or the current employment of a spouse of any age. Who pays first?
Pays first	Pays second
Medicare If the client or client spouse's employer has fewer than 20 employees, Medicare is the primary payer for all beneficiaries enrolled in the group health plan.	Group health plan
Group health plan If the client or client spouse's employer has 20 or more employees, and covers any of the same services as Medicare. This means that the group health plan is the primary payer. The group health plan pays first on the client's medical bills.	Medicare If the group health plan did not pay the entire client bill, the provider should submit the bill to Medicare for secondary payment. Medicare will review what the client or client spouse's employer group health plan paid for Medicare-covered health care services, and pay any additional costs up to the Medicare-approved amount.
The client is under 65, disabled, has Medicare and group health coverage. Who pays first?
Pays first	Pays second
Medicare If your clients' employer has less than 100 employees, Medicare is the primary payer if your client is under age 65, and has Medicare because of a disability.	Group Health Plan
Large Group Health Plan If the client's employer or client spouse's employer has 100 employees or more, the health plan is called a large group health plan. If client is covered by a large group health plan because of current employment or the current employment of a family member, Medicare is the secondary payer.	Medicare Sometimes employers with fewer than 100 employees join other employers in a multi-employer plan. If at least one employer in the multi-employer plan has 100 employees or more, then Medicare is the secondary payer for disabled Medicare beneficiaries enrolled in the plan, including those covered by small employers. Some large group health plans let others join the plan, such as a self-employed person, a business associate of an employer, or a family member of one of these people. A large group health plan cannot treat any of its plan members differently because they are disabled and have Medicare. EXAMPLE: Mary works full-time for GHI Company, which has 120 employees. She has large group health plan coverage for herself and her husband. Her husband has Medicare because of a disability. Therefore, Mary's group health plan coverage pays first for Mary's husband's expenses, and Medicare is his secondary payer.
A client has Medicare and Veterans' benefits. Who pays first?
If a client has or can get both Medicare and Veterans' benefits, the client can get treatment under either program. When a client gets health care, the client must choose which benefits they are going to use. A client must make this choice each time the client gets health care, Medicare cannot pay for the same service that was covered by Veterans' benefits, and a clients Veterans' benefits cannot pay for the same service that was covered by Medicare. Are there any situations when both Medicare and VA can pay? Yes. If the VA authorizes services in a non-VA setting, but does not pay for the services then Medicare may pay for the Medicare-covered services that the VA does not pay for. You can get more information on Veterans' benefits by calling your local VA office, or the national VA information number 800/827-1000. Or, you can use a computer to look on the Internet at http://www.va.gov.
The client has both Medicare and TRICARE. Who pays first? There are three groups of people who can have both TRICARE and Medicare Part B. They are: Dependents of active duty service members; People who are entitled only to Medicare Part B; People who are under age 65 and entitled to Medicare Part A because of a disability or ESRD and take Medicare Part B.
Pays first	Pays second
In general, Medicare pays first. If Medicare does not pay the entire bill, TRICARE may pay some of the costs. TRICARE will pay up to the amount they would have paid if the client did not have Medicare. For example, TRICARE may pay the Medicare deductible and coinsurance amounts, and for any services not covered by Medicare but covered by TRICARE.	TRICARE, since Medicare does not usually pay for services a client gets from a federal provider or other federal agency. You can get more information on TRICARE by calling the health benefits advisor at a military hospital or clinic. Or, you can use a computer to look on the Internet at www.tricare.osd.mil.
The client has Medicare or COBRA continuation coverage. Who pays first?
Pays first	Pays second
Medicare If your client is age 65 or over and has COBRA continuation coverage, Medicare is the primary payer. If a client has Medicare based on a disability and COBRA continuation coverage, Medicare is the primary payer.	COBRA

Adapted from Medicare publication #02179 "Medicare and Other Health Benefits: Your Guide to Who Pays First"; revised 3/01/00 accessed at http://www.medicare.gov/Publications/Search/View/ViewPubList.asp?Language=English