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CENTERS FOR MEDICARE & MEDICAID SERVICES

Medicare and Other Health

Benefits: Your Guide to 

Who Pays First

This official government

booklet tells you

How Medicare works with other 

types of insurance or coverage

Who should pay your bills first

Where to get more help
Welcome

“I used this Guide

when I needed

to know who

paid first for my

health care.” 

Welcome to

Medicare and Other Health Benefits:

Your Guide to Who Pays First

How This Guide Can Help You

This Guide explains how Medicare works with other kinds of insurance

or coverage and who should pay your bills first. Some people with

Medicare have other insurance or coverage that must pay before

Medicare pays its share of your bill. You may have more than one type

of insurance or coverage that will pay before Medicare. Tell your

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

insurance or coverage to make sure your bills are sent to the right payer

to avoid delays.
Table of Contents

Section 1: The Medicare Program . . . . . . . . . . . . . . . . . . . 1–4

What Is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Medicare Part A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Medicare Part B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Medicare Part C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Medicare Part D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Medicare Plan Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3–4

Section 2: Basic Information . . . . . . . . . . . . . . . . . . . . . . 5–10

Know Who Pays First . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5–7

General Information about Medicare and Other Insurance 

or Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8–9

Section 3: Medicare and Other Types of Insurance or

Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11–32

Medicare and Group Health Plan Coverage . . . . . . . . . . . . . . . . . 12–14

Medicare and Group Health Plan Coverage After You Retire . . . 14–16

Medicare and Group Health Plan Coverage for People 

Who Are Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16–17

Medicare and Group Health Plan Coverage for People with ESRD . . 18

Medicare and No-fault or Liability Insurance . . . . . . . . . . . . . . . 19–22

Medicare and Workers’ Compensation . . . . . . . . . . . . . . . . . . . . 22–26

Medicare and Veterans’ Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 26–28

Medicare and TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28–29

Medicare and the Federal Black Lung Program . . . . . . . . . . . . . . 29–30

Medicare and COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30–32

Section 4: Words to Know . . . . . . . . . . . . . . . . . . . . . . . 33–34

Where words in red are defined

Section 5: Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35–36

An alphabetical list of what is in this Guide
“We keep this booklet

with other insurance

papers so we know

where to find it if we

have a question.”
1

Words in

red are

defined

on pages

33–34.

1Section 1: The Medicare Program

What Is Medicare?

Medicare is health insurance for people age 65 or older, under age 65

with certain disabilities, and any age with End-Stage Renal Disease

(permanent kidney failure requiring dialysis or a kidney transplant).

Medicare has

• Medicare Part A (Hospital Insurance)

• Medicare Part B (Medical Insurance)

• Medicare Part C (combines Part A and Part B coverage) 

• Medicare Part D (prescription drug coverage)

Medicare Part A

Medicare Part A helps cover inpatient care in hospitals, including

critical access hospitals. It also covers skilled nursing facility, hospice,

and home health care. You must meet certain conditions to get these

benefits.

Cost: You usually don’t pay a monthly premium for Part A coverage

if you or your spouse paid Medicare taxes while working.

You pay up to $461 (in 2010) each month if you don’t get 

premium-free Part A. If you pay a late enrollment penalty, this

amount is higher.
2

Section 1: The Medicare Program

Words in

red are

defined

on pages

33–34.

Medicare Part B

Medicare Part B helps cover medical services like doctors’ services,

outpatient care, and other medical services Medicare Part A doesn’t

cover, if those services are medically necessary. Medicare Part B is

optional. You have to enroll in Part B and pay a monthly premium.

Your monthly premium depends on your income (see chart). Part B

also covers some preventive services.

Part B (Medical Insurance) Monthly Premium

Most people will continue to pay the 2009 Part B premium of $96.40 in

2010. If you have questions about your Part B premium, call Social

Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

If Your Yearly Income is (in 2008) You pay

File Individual Tax Return File Joint Tax Return

$85,000 or below $170,000 or below

$85,001-$107,000 $170,001-$214,000

$107,001-$160,000 $214,001-$320,000

$160,001-$214,000 $320,001-$428,000

Above $214,000 Above $428,000

$110.50*

$154.70

$221.00

$287.30

$353.60

*

You also pay a Medicare Part B deductible ($155 in 2010) each year

before Medicare starts to pay its share. Medicare premium and

deductible rates may change every year in January.

Medicare Part C

Medicare Advantage Plans (Part C) are another way to get your Medicare

benefits. They combine Part A, Part B, and, sometimes, Part D

(prescription drug) coverage. Medicare Advantage Plans are managed by

private insurance companies approved by Medicare. These plans must

cover medically-necessary services. However, plans can charge different

copayments, coinsurance, or deductibles for these services.

Medicare Part D

Medicare prescription drug coverage (Part D) is available to everyone

with Medicare. Private companies approved by Medicare provide this

coverage. If you are in Original Medicare, you choose a separate

Medicare Prescription Drug Plan and pay a monthly premium. 

See page 4 for more information about Medicare Prescription Drug

Coverage. Costs vary by plan.
3

Section 1: The Medicare Program

Below and on page 4 is a quick look at your Medicare plan choices.

People with Medicare can make changes to their coverage from 

November 15—December 31 each year.

Original Medicare—This is a fee-for-service plan that is managed by

the Federal government. You can go to any doctor or supplier that is

enrolled in Medicare and accepts new Medicare patients. No referrals are

necessary.

Original Medicare covers most health care services and supplies, but

it doesn’t cover most prescription drugs. It only covers certain drugs

(like certain cancer drugs). If you don’t have prescription drug

coverage through another source (your employer, the VA, etc.) you

may want to enroll in a Medicare Prescription Drug Plan to help pay

for your prescription drugs. Also, you may want to buy additional

coverage, such as a Medigap (Medicare Supplement Insurance)

policy. You can choose one or both types of additional coverage. 

Medicare Advantage Plans (like an HMO or PPO)—Medicare

Advantage Plans are health plan options approved by Medicare and run

by private companies. These plans are part of the Medicare Program and

are sometimes called “Part C” or “MA plans.” Medicare pays an amount

for your care every month to these private health plans. Medicare

Advantage Plans must follow rules set by Medicare. Medicare Advantage

Plans aren’t supplemental insurance.

Medicare Advantage Plans include the following:

• Medicare Preferred Provider Organization (PPO) Plans 

• Medicare Health Maintenance Organization (HMO) Plans 

• Medicare Private Fee-for-Service (PFFS) Plans 

• Medicare Special Needs Plans 

• Medicare Medical Savings Account (MSA) Plans 

There are other Medicare health plans that provide health care

coverage that aren’t part of Medicare Advantage but are still part of

the Medicare Program. They include Medicare Cost Plans,

Demonstrations/Pilot Programs, and PACE (Programs of

All-inclusive Care for the Elderly).
4

Section 1: The Medicare Program

Medicare Prescription Drug Coverage—Medicare offers

prescription drug coverage for everyone with Medicare. This is called

“Part D.” This coverage may help lower prescription drug costs and

help protect against higher costs in the future. It can give you greater

access to drugs that you can use to prevent complications from

diseases and stay well.

There are two ways to get Medicare prescription drug coverage:

1) Join a Medicare Prescription Drug Plan that adds drug coverage

to Original Medicare, some Medicare Cost Plans, some

Medicare Private Fee-for-Service Plans, and Medicare Medical

Savings Account Plans.

2) Join a Medicare Advantage Plan or other Medicare health plan

that includes prescription drug coverage as part of the plan. You

get all of your Medicare coverage through these plans, including

prescription drugs.

Generally, both types of these plans are called “Medicare drug plans.”

If you don’t join a Medicare drug plan when you are first eligible, the

next chance you have to join is from November 15—December 31

each year. If you decide later that you want to join a Medicare drug

plan, you may have to pay a penalty unless you had certain other

kinds of prescription drug coverage.

Important: If you have prescription drug coverage through an

employer or union, before you sign up for Medicare drug coverage

you need to check with your benefits administrator to learn how your

current coverage would be affected. In addition, if you have other

insurance that pays for your prescriptions and you join a Medicare

drug plan, you must let your Medicare drug plan know about your

other coverage.

For more information about Medicare drugs plans, get a free copy of

“Your Guide to Medicare Prescription Drug Coverage” by visiting

www.medicare.gov/Publications/Pubs/pdf/11109.pdf or call 

1-800-MEDICARE (1-800-633-4227). TTY users should call 

1-877-486-2048.

Words in

red are

defined

on pages

33–34.
2

5

Section 2: Basic Information

Know Who Pays First If You Have Other Health Insurance or

Coverage

If you have Medicare and other health insurance or coverage, each type of coverage

is called a “payer.” When there is more than one payer, there are “coordination of

benefits” rules that decide which one pays first. The “primary payer” pays what it

owes on your bills first, and then sends the rest to the “secondary payer” to pay. 

In some cases, there may also be a third payer.

Whether Medicare pays first depends on a number of things, including the

situations listed in the chart on the next two pages. However, this chart doesn’t cover

every situation. 

Be sure to tell your doctor and other providers if you have coverage in addition to

Medicare. This will help them send your bills to the correct payer to avoid delays. If you

have questions about who pays first or if your insurance changes, call the Medicare

Coordination of Benefits Contractor (COBC) at 1-800-999-1118. TTY users should

call 1-800-318-8782. 
6

Section 2: Basic Information

If you

Are 65 or older and covered

by a group health plan

because you or your spouse is

still working 

Have an employer group

health plan after you retire

and are 65 or older

Are disabled and covered

by a large group health

plan from your work, or

from a family member who

is working

Have End-Stage Renal

Disease (permanent kidney

failure) and group health

plan coverage (including a

retirement plan)

Have End-Stage Renal

Disease (permanent kidney

failure) and COBRA

coverage

Are 65 or over OR disabled

and covered by Medicare

and COBRA coverage

Entitled to Medicare

The employer has 20 

or more employees

The employer has less

than 20 employees.*

Entitled to Medicare

Entitled to Medicare

The employer has 100

or more employees.

The employer has less

than 100 employees.

First 30 months of

eligibility or

entitlement to

Medicare

After 30 months

First 30 months of

eligibility or

entitlement to

Medicare

After 30 months

Entitled to Medicare

Group 

Health Plan

Medicare

Medicare

Large Group Health Plan

Medicare

Group Health Plan

Medicare

COBRA 

Medicare

Medicare

Pays first

Medicare

Group 

Health Plan

Retiree Coverage

Medicare

Group Health Plan

Medicare

Group Health Plan

Medicare 

COBRA

COBRA

12

13

14–16

16–17

16

18

18

31

18

30–31

Situation Pays second See

page(s)

* If your employer participates in a plan that is sponsored by two or more employers, the rules are slightly different.
7

Section 2: Basic Information

If you

Have been in an accident

where no-fault or liability

insurance is involved

Are covered under workers’

compensation because of a

job-related illness or injury

Are a Veteran and have

Veterans’ benefits

Are covered under

TRICARE

Have black lung disease and

covered under the Federal

Black Lung Program

Entitled to Medicare

Entitled to Medicare

Entitled to Medicare

and Veterans’ benefits

Entitled to Medicare

and TRICARE

Entitled to Medicare

and Federal Black

Lung Program

No-fault or Liability

insurance for services related

to accident claim

Workers’ compensation for

services related to workers’

compensation claim

Medicare pays for Medicarecovered services.

Veterans’ Affairs pays for

VA-authorized services.

Note: Generally, Medicare

and VA can’t pay for the

same service.

Medicare pays for Medicarecovered services.

TRICARE pays for services

from a military hospital or

any other federal provider.

Federal Black Lung

Program for services related

to black lung 

Pays first

Medicare

Usually doesn’t

apply. However,

Medicare may make

a conditional

payment.

Usually doesn’t

apply 

TRICARE may pay

second.

Medicare

19–22

22–26

26–28

28–29

29–30

Situation Pays second See

page(s)
8

Section 2: Basic Information

Words in

red are

defined

on pages

33–34.

General Information about Medicare and Other

Insurance or Coverage

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

or coverage?

Medicare doesn’t automatically know if you have other insurance or

coverage. Medicare sends you a questionnaire called the “Initial

Enrollment Questionnaire” about 3 months before you’re entitled to

Medicare. This questionnaire will ask you if you have group health

plan coverage through your work or that of a family member. Your

answers to this questionnaire are used to help Medicare set up your

file and make sure your claims are paid correctly.

Example

Harry is almost 65 and is getting ready to retire and enroll in

Medicare. Harry’s wife, Jane, is 63, and works for a large

company (more than 20 people). Both Harry and Jane have

health insurance coverage through Jane’s employer’s group

health plan. When Harry gets the Initial Enrollment

Questionnaire in the mail from Medicare, he fills it out and

reports that he has insurance through his wife’s employment.

This insurance will pay Harry’s claims first, and Medicare will

pay claims second.

What happens if my health insurance or coverage changes 

after I fill out the Initial Enrollment Questionnaire? 

If your health insurance or coverage changes, you will need to call the

Medicare Coordination of Benefits Contractor at 1-800-999-1118. TTY

users should call 1-800-318-8782. Give the Medicare Coordination of

Benefits Contractor your name; the name and address of your health

plan; your policy number; and the date coverage was added, changed or

stopped, and why. Tell your doctor and other providers about the

change in your insurance or coverage when you get care.
9

Section 2: Basic Information

Words in

red are

defined

on pages

33–34.

General Information about Medicare and Other Insurance or

Coverage (continued)

What if I have Medicare and more than one type of insurance or

coverage?

If you have a question about who should pay, or who should pay first,

check your insurance policy or coverage. It may include the rules about

who pays first. You can also call the Medicare Coordination of Benefits

Contractor at 1-800-999-1118. TTY users should call 1-800-318-8782.

When is Medicare a secondary payer for domestic partners with

group health insurance coverage?

Medicare is generally a secondary payer for domestic partners: 

• When the domestic partner is entitled to Medicare on the basis of

disability and covered by a large group health plan on the basis of

his/her own current employment status or that of a family member

(A domestic partner is considered a family member);

• For a 30-month coordination period when the domestic partner is

eligible for Medicare on the basis of end stage renal disease (ESRD)

and is covered by a group health plan on any basis;

• When the domestic partner is entitled to Medicare on the basis of

age and has group health plan coverage on the basis of his/her own

current employment status.

When is Medicare a primary payer for domestic partners with

group health insurance coverage?

If a domestic partner is entitled to Medicare on the basis of age and has

group health plan coverage based on the current employment status of

his/her partner.

Who should I call if I have a general question about who pays first?

You should call the benefits administrator at your health insurance plan.

You can also call the Medicare Coordination of Benefits Contractor at

1-800-999-1118. TTY users should call 1-800-318-8782.
10

Section 2: Basic Information

Notes
11

3Section 3: Medicare and Other Types of Insurance or Coverage

This section has more detailed information about the different

types of coverage you might have, and how they work with

Medicare.

Section 3 includes

Medicare and Group Health Plan Coverage . . 12–14

Medicare and Group Health Plan Coverage 

After You Retire . . . . . . . . . . . . . . . . . . . . 14–16

Medicare and Group Health Plan Coverage for

People Who are Disabled . . . . . . . . . . . . . 16–17

Medicare and Group Health Plan Coverage for

People with ESRD . . . . . . . . . . . . . . . . . . . . . 18

Medicare and No-fault or Liability Insurance . 19–22

Medicare and Workers’ Compensation . . . . . 22–26

Medicare and Veterans’ Benefits . . . . . . . . . . . 26–28

Medicare and TRICARE . . . . . . . . . . . . . . . . 28–29

Medicare and the Federal Black Lung Program . 29–30

Medicare and COBRA . . . . . . . . . . . . . . . . . . 30–32
12

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Group Health Plan Coverage

When you turn 65, you have a number of important decisions to make. 

These may include whether to enroll in Medicare Part B, join a Medicare

Prescription Drug Plan, buy a Medigap policy, and/or keep employer or

retiree coverage. Understanding your choices may help you avoid paying more

than you need to for Medicare Part B and other insurance, and get the

coverage that’s best for you. You can visit www.medicare.gov and select

“Compare Medicare Prescription Drug Plans” and “Compare Health Plans

and Medigap Policies in Your Area.” You can also call your State Health

Insurance Assistance Program. To get their telephone number, call

1-800-MEDICARE (1-800-633-4227). TTY users should call 

1-877-486-2048.

What is group health plan coverage?

Group health plan coverage is coverage offered by many employers and

unions for current employees or retirees. You may also get group health

plan coverage through the employer of a spouse or family member.

If you have Medicare and you are offered coverage under a group health

plan, you can choose to accept or reject the plan. Note that the group

health plan may be a fee-for-service plan or a managed care plan, like an

HMO or PPO.

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

Generally, your group health plan pays first if the following conditions apply:

• You’re age 65 or older and covered by a group health plan because of your

current employment or the current employment of a spouse of any age. 

• The employer has 20 or more employees and covers any of the same

services as Medicare. This means that the group health plan pays first on

your hospital and medical bills. If the group health plan didn’t pay all of

your bill, the doctor or provider should send the bill to Medicare for

secondary payment. Medicare will review what your group health plan

paid, and pay any additional costs up to the Medicare-approved

amounts. You will have to pay the costs of services that Medicare or the

group health plan doesn’t cover.
13

Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Group Health Plan Coverage (continued)

I have Medicare, and I work for a small company that has a group

health plan. Who pays first?

If your employer has fewer than 20 employees, Medicare generally pays first.

But if your employer joins with other employers or employee organizations

(like unions) to sponsor a group health plan (called a multi-employer plan),

and any of the other employers have 20 or more employees, Medicare would

generally pay second. However, your plan might ask for an exception. So

even if your employer has fewer than 20 employees, you will need to find

out from your employer whether Medicare pays first or second.

If my group health plan is a Health Maintenance Organization

(HMO) Plan or an employer Preferred Provider Organization (PPO) 

Plan that is primary to Medicare, who pays if I go outside the

employer plan’s network?

If you go outside your employer plan’s network, you might not get any

payment from the plan or Medicare. Call your employer plan before you

go outside the network to find out if the service will be covered.

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

Will this affect what Medicare will pay?

If you don’t take group health plan coverage from your employer and you

don’t have coverage through an employed spouse, Medicare payment isn’t

affected. Medicare will pay its share for any Medicare-covered health care

service you get.

What happens if I drop coverage from my employer?

Medicare pays first unless you have coverage through an employed spouse,

and your spouse’s employer has at least 20 employees.

Note: If you don’t take or you drop employer coverage when it is first

offered to you, you might not get another chance to sign up. If you take

the coverage, but later drop it, you may not be able to get it back. Also, if

your or your spouse’s employer generally offers retiree coverage (see 

page 14), you might be denied that coverage if you weren’t enrolled in the

plan while you or your spouse was still working. Call your employer’s

benefits administrator for more information before you make a decision.
14

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Group Health Plan Coverage (continued)

What health benefits must my employer provide if I am age 65 or older

and still working?

Generally, employers with 20 or more employees must offer the same health

benefits, under the same conditions, to current employees age 65 and older as

they offer to younger employees. If the employer offers coverage to spouses,

they must offer the same coverage to spouses age 65 and older that they offer

to spouses under age 65.

Medicare and Group Health Plan Coverage After 

You Retire

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

This will depend on the terms of your specific plan. Your or your spouse’s

employer or union might not provide any health coverage after you retire. If

group health plan coverage continues to be available after you retire, it might

have different rules, and it might not work the same way with Medicare. 

First, find out if you can continue your employer coverage after you retire.

Note that employers aren’t required to provide retiree coverage, and they can

change the benefits or premiums, or even cancel the coverage.

Second, find out what happens to your retiree coverage when you’re eligible

for Medicare. For example, retiree coverage might not pay your medical costs

during any period in which you were eligible for Medicare but didn’t sign up

for it. When you become eligible for Medicare, you may need to enroll in

both Medicare Part A and Medicare Part B to get full benefits from your

retiree coverage.
15

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Group Health Plan Coverage After You Retire

(continued)

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

Since Medicare pays first after you retire, your retiree coverage is likely to be

similar to coverage under a Medigap (Medicare Supplement Insurance)

policy. Retiree coverage isn’t the same thing as a Medigap policy. However,

like a Medigap policy, it usually offers benefits that fill in some of Medicare’s

gaps in coverage, such as coinsurance and deductibles, and it sometimes

includes extra benefits, like coverage for extra days in the hospital. 

Check the price and benefits of the retiree coverage, including whether it

includes coverage for your spouse. Retiree coverage provided by your

employer or union may have limits on how much it will pay. It might only

provide “stop loss” coverage, which starts paying your out-of-pocket costs

only when they reach a maximum amount. 

It would make sense to compare the retiree coverage to available Medigap

policies. The best time to buy a Medigap policy is during your 6-month open

enrollment period, when you can buy any Medigap policy sold in your state,

even if you have health problems. This period automatically starts the month

you’re age 65 and enrolled in Part B, and once it’s over, you can’t get it again.

Also, remember that you and your spouse would each have to have your own

Medigap policy, and you can only buy a policy when you’re eligible for

Medicare. For more information about Medigap policies, visit

www.medicare.gov/Publications/Pubs/pdf/02110.pdf to view the booklet

“Choosing a Medigap Policy: A Guide to Health Insurance for People with

Medicare.” To find and compare Medigap plocies, visit www.medicare.gov and

select “Compare Medicare Health Plans and Medigap Policies in Your Area.”

Or, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 

1-877-486-2048.

Make sure you know what effect your continued coverage as a retiree will

have on both your and your spouse’s health coverage. If you aren’t sure how

your retiree coverage works with Medicare, get a copy of your plan’s benefit

booklet, or look at the summary plan description provided by your employer

or union. You can also call your employer’s benefits administrator and ask

how the plan pays when you have Medicare. It would also be a good idea to

talk to your State Health Insurance Assistance Program (SHIP) for advice

about whether to buy a Medigap policy.
16

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Group Health Plan Coverage After You Retire

(continued)

Note: Generally, when you have retiree coverage from an employer

or union, they control this coverage. They may change the benefits

or the premiums and can also cancel the coverage if they choose.

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

coverage from my former employer. Who pays first?

Generally, Medicare will pay first for your health care bills and your

group health plan (retiree) coverage will pay second.

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

and my former employer goes bankrupt or out of business?

If your former employer goes bankrupt or out of business, you may

be protected under Federal COBRA rules if there is any other

company within the same corporate organization that still offers a

group health plan to its employees. If there is, that plan is required

to offer you COBRA continuation coverage through that plan. See

pages 30–32. If COBRA continuation coverage isn’t available, you

may have the right to buy a Medigap policy, even if you’re no longer

in your Medigap open enrollment period.

Medicare and Group Health Plan Coverage for

People Who Are Disabled (Non-ESRD Disability)

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

plan coverage based on current employment. Who pays first?

It depends. Generally, if your employer has less than 100 employees, 

Medicare pays first if the following are true:

• You are under age 65.

• You have Medicare because of a disability.

If the employer has 100 employees or more, the health plan is called

a large group health plan. If you are covered by a large group health

plan because of your current employment or the current

employment of a family member, Medicare pays second.
17

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and 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

plan coverage based on current employment. Who pays first?

Sometimes employers with fewer than 100 employees join other

employers to form a multi-employer plan. If at least one employer in

the multi-employer plan has 100 employees or more, then Medicare

pays second. 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

can’t treat any of its plan members differently because they’re

disabled and have Medicare.

Example

Mary works full-time for XYZ 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, and Medicare pays second.
18

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Group Health Plan Coverage for

People with End-Stage Renal Disease (ESRD)

(permanent kidney failure)

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

If you’re eligible for Medicare because of ESRD, your group health

plan will pay first on your hospital and medical bills for 30 months,

whether or not you’re enrolled in Medicare and have a Medicare card.

During this time, Medicare pays second. The group health plan pays

first during this period no matter how many employees work for your

employer, or whether you or a family member are currently employed.

At the end of the 30 months, Medicare pays first. This rule applies to

most people with ESRD, whether you have your own group health

plan coverage, or you’re covered as a family member.

Example

Bill has Medicare coverage because of ESRD (permanent kidney

failure). He also has group health plan coverage through his

company. Bill’s group health plan coverage will pay first for the

first 30 months after he becomes eligible for Medicare. After 30

months, Medicare pays first.
19

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and No-fault or Liability Insurance

What is no-fault insurance?

No-fault insurance is insurance that pays for health care services resulting

from injury to you or damage to your property in an accident, regardless

of who is at fault for causing the accident.

Some types of no-fault insurance include, but aren’t limited to, the following:

• Automobile insurance

• Homeowners’ insurance

• Commercial insurance plans

What is liability insurance?

Liability insurance is coverage that protects the policyholder against

claims for negligence, inappropriate action, or inaction that results in

injury to someone or damage to property.

Liability insurance includes, but isn’t limited to, the following:

• Homeowners’ liability insurance

• Automobile liability insurance

• Product liability insurance

• Malpractice liability insurance

• Uninsured motorist liability insurance

• Underinsured motorist liability insurance 

If you have an insurance claim for your medical expenses, you or your

attorney should notify Medicare as soon as possible.
20

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and No-fault or Liability Insurance (continued)

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

No-fault insurance or liability insurance pays first and Medicare pays

second, if appropriate.

Example

Nancy is 69 years old. She’s a passenger in her granddaughter’s

car, and they have an accident. Nancy’s granddaughter has

Personal Injury Protection/Medical Payments (Med Pay) coverage

as part of her automobile insurance. While at the hospital

emergency room, Nancy is asked about available insurance

coverage related to the accident. Nancy tells the hospital that her

granddaughter has Med Pay coverage. Because this insurance pays

regardless of fault, it is considered no-fault insurance. The hospital

bills the no-fault insurance for the emergency room services, and

only bills Medicare if any Medicare-covered services aren’t paid

for by the liability insurance.

If I expect to get money from no-fault or liability insurance, 

and I also have Medicare, which one should pay first?

As explained on page 19, no-fault or liability insurance should pay first.

Note: Paying “first” means paying the whole bill up to the limits of the

coverage. It doesn’t always mean that the primary payer pays first in

time. If doctors or other providers are told that you have a no-fault or

liability insurance claim, they must try to get payments from the

insurance company before billing Medicare. However, this may take a

long time. If the insurance company doesn’t pay the claim promptly

(usually within 120 days), your doctor or other provider may bill

Medicare. Medicare may make a conditional payment to pay the bill, and

then later recover any payments that the primary payer should have made.
21

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and No-fault or Liability Insurance (continued)

What is a conditional payment?

A conditional payment is a payment that Medicare makes for services

for which another payer is potentially responsible. This conditional

payment is made so you won’t have to use your own money to pay

the bill. The payment is “conditional” because it must be repaid to

Medicare when a settlement, judgment, or award is reached.

Note: If Medicare makes a conditional payment, and you get a

settlement from an insurance company later, Medicare will recover the

conditional payment from your settlement. You are responsible for

making sure that Medicare gets repaid for the conditional payment.

Example

Joan is driving her car when someone in another car hits her. Joan

has to go to the hospital. The hospital tries to bill the other driver’s

liability insurer. The insurance company disputes who was at fault

and won’t pay the claim right away. The hospital bills Medicare,

and Medicare makes a conditional payment to the hospital for

health care services that Joan received. Later, when a settlement is

reached with the liability insurer, Joan must make sure that

Medicare gets its money back for the conditional payment.
22

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and No-fault or Liability Insurance (continued)

How does Medicare get its money back for the conditional

payment?

If Medicare makes a conditional payment, you or your representative should

call the Medicare Coordination of Benefits Contractor (COBC) at 

1-800-999-1118. TTY users should call 1-800-318-8782. The COBC will

notify the recovery contractor to work on your case. The recovery contractor

is a separate contractor responsible for getting conditional payments repaid to

Medicare.

The recovery contractor will use the information you or your representative

gave to the COBC. It will gather information about any conditional

payments Medicare made which relate to your pending settlement,

judgment, or award. Once a settlement, judgment, or award is final, you or

your representative should call the recovery contractor. The recovery

contractor will get the final repayment amount (if 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?

In this case, Medicare will pay the same as it would if it were the only

payer. However, Medicare will only pay for Medicare-covered services, and

you will be responsible for your share of the bill (for example, coinsurance,

copayment, or deductible) and for services that Medicare doesn’t cover.

Who should I call if I have questions?

If you have questions about a no-fault or liability insurance claim, 

call the insurance company. If you have questions about who pays first,

call the Medicare Coordination of Benefits Contractor at 

1-800-999-1118. TTY users should call 1-800-318-8782.

Medicare and Workers’ Compensation

What is workers’ compensation?

Workers’ compensation is a law or plan of the United States or any

state, that requires employers to cover employees who get sick or

injured on the job. Most employees are covered under workers’

compensation plans. If you don’t know whether you’re covered, ask

your employer, or contact your state workers' compensation division or

department.
23

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Workers’ Compensation (continued)

I have Medicare and filed a workers’ compensation claim. 

Who pays first?

If you have Medicare and get injured on the job, workers’ compensation pays

first on the bills for health care items or services you got because of your

work-related illness or injury. There can be a delay between when a bill is

filed for the work-related illness or injury and when the state workers’

compensation insurance decides if they should pay the bill. Medicare can’t

pay for items or services that workers’ compensation will pay for promptly

(usually 120 days). However, if the workers’ compensation insurer denies

payment for your medical bills pending a review of your claim, Medicare may

make a conditional payment.

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 Medicare Coordination of Benefits

Contractor (COBC) at 1-800-999-1118 as soon as you file your workers’

compensation claim. TTY users should call 1-800-318-8782. 

Example

Tom was injured at work. He filed a claim for workers’ compensation

insurance. His doctor billed the state workers’ compensation insurance

for payment. Payment wasn’t received in 120 days. Tom’s doctor

billed Medicare and sent a copy of the workers’ compensation claim

with the claim for Medicare payment. Medicare can make a

conditional payment to the doctor for the health care services that

Tom received. When a settlement is reached with the state workers’

compensation agency, Tom must make sure that Medicare gets its

money back for the conditional payment.

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

If Medicare makes a conditional payment, and you or your lawyer haven’t

reported your worker’s compensation claim to Medicare, you should call

the Medicare Coordination of Benefits Contractor (COBC) at 

1-800-999-1118. TTY users should call 1-800-318-8782. 
24

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Workers’ Compensation (continued)

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

(continued)

If your lawyer contacts Medicare for you, your lawyer should call the

Coordination of Benefits Contractor (COBC) at 1-800-999-1118. 

TTY users should call 1-800-318-8782. The COBC will notify the recovery

contractor to work on your case. The recovery contractor will use the

information that you or your lawyer gave to the COBC. It will gather

information about any conditional payments Medicare made that relate to

your pending settlement, judgment, or award. Once a settlement, judgment,

or award is final, you or your lawyer should call the recovery contractor. 

The recovery contractor will identify the final repayment amount (if any) on

your case and issue a letter requesting repayment.

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

Settlements of workers’ compensation claims are handled differently than a

settlement of a no-fault or liability insurance claim. As part of settling your

workers’ compensation claim, you must repay Medicare for any Medicare

payments for workers’ compensation claim-related services that you have

already received. However, the settlement may also provide for funds to be

set aside to pay for future medical and/or prescription drug services related

to the workers’ compensation injury or illness/disease. 

When you have Medicare, these funds should be deposited into a Workers’

Compensation Medicare Set-aside Arrangement (WCMSA), which may be

set up by your workers’ compensation lawyer. The purpose of the WCMSA

is to make sure the workers’ compensation funds are spent on expenses that

would otherwise by covered by Medicare. In other words, workers'

compensation pays before Medicare, even after a settlement.

If you want to settle your workers’ compensation claim, you or your lawyer

should contact the recovery contractor. If your proposed settlement includes

funds for any future medical services and/or prescription drug expenses, you

or your lawyer should send your proposed WCMSA to the Medicare

Coordination of Benefits Contractor at the address below:

CMS

c/o Coordination of Benefits Contractor

P.O. Box 33849

Detroit, MI 48232

Attention: WCMSA Proposal
25

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Workers’ Compensation (continued)

I have a Workers’ Compensation Medicare Set-aside Arrangement

(WCMSA). How do I use the money if I manage (self-administer) my

Medicare set-aside arrangement?

If you have a WCMSA as part of your workers’ compensation settlement,

you must be careful how you spend the money that was specifically set

aside for Medicare. The money that was placed in your WCMSA is to

pay for future medical and/or prescription drug expenses related to your

work injury or illness/disease that would otherwise have been covered

(payable) by Medicare. This means you can’t use the WCMSA to pay for

any other work injury, or any medical items or services that Medicare

doesn’t cover (for example, dental services). 

In addition, Medicare won’t pay for any medical expenses related to the injury

until after you have used all of your set-aside money appropriately. If you

aren’t sure what type of services Medicare covers, you should call Medicare for

more information before you use any of the money that was placed in your

WCMSA. For more information, call Medicare at 1-800-MEDICARE

(1-800-633-4227). TTY users should call 1-877-486-2048.

Be sure to keep records of your workers’ compensation-related medical

and/or prescription drug expenses. These records show what items and

services you got and how much money you spent on your work injury or

illness/disease. You will need these records to prove that you used your

WCMSA money to pay your workers’ compensation-related medical

and/or prescription drug expenses. After you use all of your WCMSA

money appropriately, Medicare can start paying for Medicare-covered

services related to your work injury or illness/disease.

Note: Workers’ compensation claims can be resolved by settlements,

judgments, or awards. The information listed here about WCMSAs only

applies to settlements.
26

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Workers’ Compensation (continued)

What if workers’ compensation denies payment?

If the state workers’ compensation insurance denies payment, and if

you provide proof to Medicare that the claim was denied, then

Medicare will pay for Medicare-covered items and services.

Mike was injured at work. He filed a claim for workers’ compensation.

The workers’ compensation agency denied payment for Mike’s medical

bills. Mike’s doctor billed Medicare and sent a copy of the workers’

compensation denial with the claim for Medicare payment. Medicare

will pay Mike’s doctor for the Medicare-covered items and services

Mike got as part of his treatment. Mike will have to pay for anything

Medicare doesn’t cover.

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

In some cases, workers’ compensation insurance may not pay your

entire bill. If you had an injury or illness before you started your job

(called a “pre-existing condition”), and the job made it worse, workers’

compensation may not pay your whole bill because the job didn’t

cause the original problem. In this case, workers’ compensation

insurance may agree to pay only a part of your doctor or hospital bills.

You and workers’ compensation insurance may agree to share the cost

of your bill. If Medicare covers the treatment for your pre-existing

condition, then Medicare may pay its share for part of the doctor or

hospital bills that workers’ compensation doesn’t cover.

Medicare and Veterans’ Benefits

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

If you have or can get both Medicare and Veterans’ benefits, you can get

treatment under either program. When you get health care, you must

choose which benefits to use each time you see a doctor or get health care.

Medicare can’t pay for the same service that was covered by Veterans’

benefits, and your Veterans’ benefits can’t pay for the same service that

was covered by Medicare. You don’t always have to go to a Department of

Veterans Affairs (VA) hospital or to a doctor who works with the VA for

the VA to pay for the service. To get the VA to pay for services you must

go to a VA facility or have the VA authorize services in a non-VA facility.
27

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Veterans’ Benefits (continued)

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

Yes. If the VA authorizes services in a non-VA hospital, but doesn’t

pay for all of the services you get during your hospital stay, then

Medicare may pay for the Medicare-covered part of the services that

the VA doesn’t pay for.

Bob, a veteran, goes to a non-VA hospital for a service that is

authorized by the VA. While at the non-VA hospital, Bob gets other

non-VA authorized services that the VA refuses to pay for. Some of

these services are Medicare-covered services. Medicare may pay for

some of the non-VA authorized services that Bob got. Bob will have

to pay for services not covered by Medicare or the VA.

Can Medicare help pay my VA copayment?

Sometimes. The VA charges a copayment to some veterans. The

copayment is your share of the cost of your treatment and is based

on income. Medicare may be able to pay all or part of your

copayment if you are billed for VA-authorized care by a doctor or

hospital who isn’t part of the VA.

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

The VA gives “fee-basis ID cards” to certain veterans. You may be

given a fee-basis ID card if the following conditions apply:

• You have a service-connected disability.

• You will need medical services for an extended period of time.

• There are no VA hospitals in your area.

If you have a fee-basis ID card, you may choose any doctor who is

listed on your card to treat you.

If the doctor accepts you as a patient and bills the VA for services,

the doctor must accept the VA’s payment as payment in full. The

doctor can’t bill either you or Medicare for these services.

If your doctor doesn’t accept the fee-basis ID card, you will need to

file a claim with the VA yourself. The VA will pay the approved

amount to either you or your doctor.
28

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and Veterans’ Benefits (continued)

Who should I call if I need more information?

You can get more information on Veterans’ benefits by calling your

local VA office or the national VA information number at

1-800-827-1000. TTY users should call 1-800-829-4833. You can

also visit www.va.gov.

Medicare and TRICARE

What is TRICARE?

TRICARE is a health care program for active-duty and retired

uniformed services members and their families. TRICARE includes

the following:

• TRICARE Prime

• TRICARE Extra

• TRICARE Standard

• TRICARE for Life (TFL)

What is TRICARE for Life?

TRICARE for Life (TFL) was created to provide expanded medical

coverage to Medicare-eligible uniformed services retirees age 65 or

older, their eligible family members and survivors, and certain

former spouses. To get TFL benefits, you must have Medicare 

Part A and Part B.

Can I have both Medicare and TRICARE?

The following groups of people can have both Medicare and other

types of TRICARE:

• Dependents of active-duty service members who are entitled to

Medicare for any reason

• People under age 65 who are entitled to Medicare Part A

because of a disability or End-Stage Renal Disease (ESRD) and

enrolled in Medicare Part B

• People age 65 or older who are entitled to Medicare Part A and

enrolled in Medicare Part B
29

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and TRICARE (continued)

I have Medicare and TRICARE. Who pays first?

In general, Medicare pays first for Medicare-covered services. TRICARE

will pay the Medicare deductible and coinsurance amounts and for any

service not covered by Medicare that TRICARE covers. You will have to

pay the costs of services that Medicare or TRICARE doesn’t cover.

Who pays if I get services from a military hospital?

If you get services from a military hospital or any other federal provider,

TRICARE will pay the bills. Medicare usually doesn’t pay for services

you get from a federal provider or other federal agency.

Who should I call if I need more information?

You can get more information on TRICARE by calling the health

benefits advisor at a military hospital or clinic. You can also call

1-866-773-0404, or visit www.TRICARE.osd.mil.

Medicare and the Federal Black Lung Program

I have Medicare and coverage under the Federal Black Lung

Program. Who pays first?

The Federal Black Lung Program pays first for any health care for black

lung disease covered under that program. Medicare won’t pay for doctor

or hospital services covered under the Federal Black Lung Program. Your

doctor or other provider should send all bills for the diagnosis or

treatment of black lung disease to the following address:

Federal Black Lung Program

P.O. Box 8302

London, KY 40742-8302

For all other health care not related to black lung disease, Medicare pays

first, and you should send your bills directly to Medicare.

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

If the Federal Black Lung Program won’t pay your bill, your doctor or

other provider can send the bill to Medicare. Your doctor or other

provider should send your bill and a copy of the letter from the Federal

Black Lung Program that says why it won’t pay your bill.
30

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and the Federal Black Lung Program (continued)

Who should I call if I have questions?

If you have questions about the Federal Black Lung Program, call

1-800-638-7072. If you have questions about who pays first, call

the Medicare Coordination of Benefits Contractor at 

1-800-999-1118. TTY users should call 1-800-318-8782.

Medicare and COBRA (The Consolidated Omnibus

Budget Reconciliation Act of 1985)

What is COBRA?

COBRA is a federal law that may let you keep your employer

group health plan coverage for a limited time after your

employment ends or after you would otherwise lose coverage. 

This 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 fewer than 20 employees to let you keep your

coverage for a period of time. In most situations that give you

COBRA rights, other than a divorce, you should get a notice from

your employer’s benefits administrator or the group health plan

telling you that your coverage is ending and offering you the right

to elect COBRA continuation coverage, generally for 18 months, or

in some cases 36 months. If you don’t get a notice, but you find

out that your coverage has ended, or if you get divorced, you

should call the employer’s benefits administrator or the group

health plan as soon as possible and ask about your COBRA rights.
31

Section 3: Medicare and Other Types of Insurance or Coverage

Words in

red are

defined

on pages

33–34.

Medicare and COBRA (continued)

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

In general, the rules described on pages 12–16 that apply to group health plan

coverage apply to COBRA continuation coverage as well. For example, if you

or your spouse are retired and have COBRA continuation coverage, Medicare

pays first. 

However, if you have Medicare based on End-Stage Renal Disease (ESRD),

COBRA continuation coverage pays first, and Medicare pays second to the

extent COBRA coverage overlaps the first 30 months of Medicare eligibility or

entitlement based on ESRD. 

This publication can only give a brief description of COBRA coverage and

who pays first. The decision about whether and when to elect COBRA can be

very complicated. When you lose employer coverage and you have Medicare,

you need to be aware of your COBRA election period, your Part B enrollment

period, and your Medigap open enrollment period. These may all have

different deadlines that overlap, and what you decide about one type of

coverage (COBRA, Part B, and Medigap) might cause you to lose rights under

one of the other types of coverage. 
32

Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and COBRA (continued)

Who should I call if I have questions about COBRA?

• Before you elect COBRA coverage, it’s a good idea to talk with your State

Health Insurance Assistance Program (SHIP) about Part B and Medigap.

To get their telephone number, call 1-800-MEDICARE (1-800-633-4227).

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

• You can also get a free copy of “Choosing a Medigap Policy: A Guide to

Health Insurance for People with Medicare.” You can visit

www.medicare.gov/Publications/Pubs/pdf/02110.pdf or call 

1-800-MEDICARE. 

• Call your employer’s benefits administrator for questions about your

specific COBRA options. 

• If you have questions about Medicare and COBRA, call the Medicare

Coordination of Benefits Contractor at 1-800-999-1118. TTY users should

call 1-800-318-8782.

• If your group health plan coverage was from a private employer (not a

government employer), you can visit the Department of Labor’s (DoL)

Web site at www.dol.gov, or call 1-866-444-3272.

• If your group health plan coverage was from a state or local government

employer, you can call 1-877-267-2323 extension 61565.

• If your coverage was with the Federal government, you can visit the Office

of Personnel Management’s website at www.opm.gov.
4

Section 4: Words to Know

Claim—A claim is a request for payment

that you submit to Medicare or other

health insurance when you receive items

and services that you think are covered.

Coinsurance—An amount you may be

required to pay as your share of the cost for

services, after you pay any deductibles.

Coinsurance is usually a percentage (for

example, 20%).

Copayment—An amount you may be

required to pay as your share of the cost for

a medical service or supply, like a doctor’s

visit or a prescription. A copayment is

usually a set amount, rather than a

percentage. For example, you might pay

$10 or $20 for a doctor’s visit or

prescription.

Deductible—The amount you must pay

for health care or prescriptions, before

Original Medicare, your prescription drug

plan, or your other insurance begins to pay.

End-Stage Renal Disease—Permanent

kidney failure that requires a regular course

of dialysis or a kidney transplant.

Group Health Plan—In general, a health

plan offered by an employer or employee

organization that provides health coverage

to employees, former employees, and their

families.

Large Group Health Plan—In general, a

group health plan that covers employees of

either an employer or employee

organization that has 100 or more

employees.

Medicare Coordination of Benefits

Contractor— The company that acts

on behalf of Medicare to collect and

manage information on other types of

insurance or coverage that a person

with Medicare may have, and

determine whether the coverage pays

before or after Medicare.

Medicare Part A (Hospital Insurance)—

Hospital insurance that pays for inpatient

hospital stays, care in a skilled nursing

facility, hospice care, and some home

health care.

Medicare Part B (Medical Insurance)—

Coverage for certain doctors’ services,

outpatient care, medical supplies, and

preventive services.

Medicare Prescription Drug Plan (Part

D)—A stand-alone drug plan that adds

prescription drug coverage to Original

Medicare, some Medicare Cost Plans,

some Medicare Private-Fee-for-Service

Plans, and Medicare Medical Savings

Account Plans. These plans are offered

by insurance companies and other

private companies approved by

Medicare. Medicare Advantage Plans

may also offer prescription drug coverage

that follows the same rules as Medicare

Prescription Drug Plans.

Medigap Policy—Medicare

Supplement Insurance sold by private

insurance companies to fill “gaps” in

Original Medicare coverage.

Multi-Employer Plan—In general, a

group health plan that is sponsored

jointly by two or more employers.

33
34

Section 4: Words to Know

Original Medicare—Original Medicare is

fee-for-service coverage under which the

government pays your health care

providers directly for your Part A and/or

Part B benefits.

Premium—The periodic payment to

Medicare, an insurance company, or a

health care plan for health or prescription

drug coverage.

Provider—A doctor, hospital, health care

professional, or health care facility.

Recovery Contractor—A company that

acts on behalf of Medicare to obtain

repayment when Medicare makes a

conditional payment, and the other payer

is determined to be primary.

State Health Insurance Assistance

Program(SHIP)—A state program that

gets money from the Federal government

to give free local health insurance

counseling to people with Medicare.

Workers’ Compensation—A plan that

employers are required to have to cover

employees who get sick or injured on the

job.

Workers’ CompensationMedicare SetAside Arrangements (WCMSAs)

Account—An account set up with funds

from a Workers’ Compensation settlement

to pay for future medical and/or

prescription drug expenses which are both

related to the Workers’ Compensation

injury or illness/disease and would

otherwise be covered by Medicare.
35

5 Section 5: Index

1-800-MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 12, 15, 25, 32

Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 19

Black Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 29–30

Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 8, 19–27

COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 16, 30–32

Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 15, 22, 29

Conditional Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 20–24

Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 22, 27

Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 15, 22, 29

Denial of Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16–17

End-Stage Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18, 28, 31

Federal Black Lung Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 29–30

Group Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 8, 12–18, 30–32

Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–18

Initial Enrollment Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Large Group Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 16–17

Liability Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 19–22

Medicare Advantage Plans (Part C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 3

Medicare Coordination of Benefits Contractor . . . . . . 5, 8, 9, 22–24, 30, 32

Medicare Part A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Medicare Part B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2, 12

Medicare Part C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2, 3

Medicare Prescription Drug Coverage (Part D) . . . . . . . . . . . . . . . . . . 1, 2, 4

Medicare Secondary Payer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 12

Medigap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 12, 15 , 16, 32

Multi-Employer Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13, 17

No-fault Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 19–22

Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
36

Section 5: Index

Pre-existing Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2

Primary Payer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 20

Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 7, 8, 12, 20, 29

Recovery Contractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22, 24

Retiree Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 12–16

State Health Insurance Assistance Program . . . . . . . . . . . . . . . . . . 12, 15, 32

TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 28–29

TRICARE for Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Veterans’ Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7, 26–28

Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 22–26

Workers’ Compensation Medicare Set-aside Arrangement . . . . . . . . . 24, 25

“Medicare and Other Health Benefits: Your Guide to Who Pays First” isn’t a legal

document. The official Medicare Program provisions are contained in the relevant

laws, regulations, and rulings.

The information in this booklet was correct when it was posted on www.medicare.gov.

To find out if the booklet is available in print, other formats, or if the information has

been updated, call 1-800-MEDICARE (1-800-633-4227). TTY users should call

1-877-486-2048.
37

Notes
38

Notes

U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

Official Business

Penalty for Private Use, $300

CMS Product No. 02179

Revised April 2010

• Call the Medicare Coordination of Benefits Contractor at 1-800-999-1118 with

any changes in your insurance or any questions about who pays first. TTY users

should call 1-800-318-8782.

• ¿Necesita usted una copia en español? Llame GRATIS al 1-800-MEDICARE

(1-800-633-4227). Los usuarios de TTY deberán llamar al 1-877-486-2048.