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 

If you have questions about who pays first or if your

coverage changes, call the Medicare Coordination of

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

users should call 1-800-318-8782.

Medicare and Other Health

Benefits: Your Guide to 

Who Pays First

★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★

CENTERS FOR MEDICARE & MEDICAID SERVICES
Welcome

How This Guide Can Help You

Some people with Medicare have other coverage that must pay before

Medicare pays its share of your bill. This guide tells how Medicare

works with other kinds of coverage and who should pay your bills first.

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

your other coverage to make sure your bills are sent to the right payer

to avoid delays.

Where Can I Get Basic Information on Medicare?

Get the “Medicare & You” handbook by visiting

www.medicare.gov/publications, or call 1-800-MEDICARE 

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

“Medicare and Other Health Benefits: Your Guide to Who Pays First”

isn’t a legal document. Official Medicare Program legal guidance is

contained in the relevant statutes, regulations, and rulings.

“I used this guide

when I needed

to know who

paid first for my

health care.” 

Medicare and Other Health Benefits:

Your Guide to Who Pays First

Welcome to
Table of Contents

Section 1: When You Have Other Health Coverage . . . . 1–6 

Who Pays First if I Have Other Health Coverage? . . . . . . . . . . . . . . . 1

Where to Go with Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

How Medicare Coordinates with Other Coverage . . . . . . . . . . . . . . 4–5

Section 2: Medicare and Other Types of 

Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7–24

Medicare and Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Medicare and Group Health Plan Coverage . . . . . . . . . . . . . . . . . . 8–10

Medicare and Group Health Plan Coverage After You Retire . . . 10–11

Medicare and Group Health Plan Coverage for People 

Who are Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Medicare and Group Health Plan Coverage for People with 

End-Stage Renal Disease (ESRD) . . . . . . . . . . . . . . . . . . . . . . . . . 12

Medicare and No-Fault or Liability Insurance . . . . . . . . . . . . . . . 13–15

Medicare and Workers’ Compensation . . . . . . . . . . . . . . . . . . . . 15–19

Medicare and Veterans’ Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 19–20

Medicare and TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20–21

Medicare and the Federal Black Lung Benefits Program . . . . . . . 21–22

Medicare and COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22–23

Section 3: Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . 25–26

Where words in red are defined

Section 4: Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27–28

An alphabetical list of what’s 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

25–26.

Who Pays First If I Have Other Health Coverage?

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

is called a “payer.” When there’s more than one payer, “coordination

of benefits” rules decide who pays first. The “primary payer” pays

what it owes on your bills first, and then your provider 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 health care providers if you have

coverage in addition to Medicare. This will help them send your bills

to the correct payer to avoid delays. 

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

the payer’s coverage. It doesn’t always mean the primary payer pays

first in time.

Where to Go with Questions

If you have questions about who pays first, or if your coverage

changes, call the Medicare Coordination of Benefits Contractor

(COBC) at 1-800-999-1118. TTY users should call 

1-800-318-8782.

To better serve you, please have the following information ready when

you call: your Medicare number (located on your red, white, and blue

Medicare card) and one additional piece of information, such as your

Social Security Number (SSN), address, Medicare effective date(s), or

whether you have Medicare Part A (Hospital Insurance) and/or

Medicare Part B (Medical Insurance) coverage.

1Section 1: When You Have Other Health Coverage
2

Section 1: When You Have Other Health Coverage

If you Situation Pays first Pays second See

page(s)

Are covered by Medicare

and Medicaid

Entitled to Medicare

and Medicaid

Medicare Medicaid, but only after other

coverage (such as employer

group health plans) has paid

8

Are 65 or older and covered

by a group health plan

because you or your spouse is

still working 

Entitled to Medicare Group 

health plan

Medicare

8

The employer has 20 

or more employees

The employer has less

than 20 employees*

Medicare Group health plan 9

Have an employer group

health plan after you retire

and are 65 or older

Entitled to Medicare Medicare Retiree coverage 10–11

Are disabled and covered

by a large group health

plan from your work, or

from a family member who

is working

Entitled to Medicare

The employer has 100

or more employees

Large group 

health plan

Medicare

12

The employer has less

than 100 employees

Medicare Group health plan 12

**Have End-Stage Renal

Disease (ESRD) (permanent

kidney failure requiring

dialysis or a kidney

transplant) and group health

plan coverage (including a

retirement plan)

First 30 months of

eligibility or

entitlement to

Medicare

Group health 

plan

Medicare

12

After 30 months of

eligibility or entitlement

to Medicare

Medicare Group health plan 12

Have ESRD and COBRA

coverage

First 30 months of

eligibility or

entitlement to

Medicare

COBRA Medicare 23

After 30 months Medicare COBRA 12 

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

** If you originally got Medicare due to your age or a disability other than ESRD, and Medicare was your

primary payer, it still pays first when you become eligible due to ESRD.
3

Section 1: When You Have Other Health Coverage

If you Situation Pays first Pays second See

page(s)

Are 65 or over OR disabled

and covered by Medicare

and COBRA coverage

Entitled to Medicare Medicare COBRA 22–23

Have been in an accident

where no-fault or liability

insurance is involved

Entitled to Medicare No-fault or liability

insurance for services related

to accident claim

Medicare 13–15

Are covered under workers’

compensation because of a

job-related illness or injury

Entitled to Medicare Workers’ compensation for

services related to workers’

compensation claim

Usually doesn’t

apply. However,

Medicare may make

a conditional

payment.

15–19

Are a veteran and have

Veterans’ benefits

Entitled to Medicare

and Veterans’ benefits

Medicare pays for Medicarecovered services.Usually doesn’t

apply 

19–20

Veterans’ Affairs pays for

VA-authorized services.

Note: Generally, Medicare

and VA can’t pay for the

same service.

Are covered under

TRICARE

Entitled to Medicare

and TRICARE

Medicare pays for Medicarecovered services.

TRICARE may pay

second.

20–21

TRICARE pays for services

from a military hospital or

any other federal provider.

Have black lung disease and

are covered under the

Federal Black Lung Benefits

Program

Entitled to Medicare

and the Federal Black

Lung Benefits

Program

The Federal Black Lung

Benefits Program for

services related to black

lung 

Medicare 21–22
4

Section 1: When You Have Other Health Coverage

How Medicare Coordinates with Other Coverage

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

About 3 months before you get Medicare, Medicare will send you a letter with a

username and password for MyMedicare.gov, a free, secure online service where you can

keep personalized information on your Medicare benefits and services. Medicare doesn’t

automatically know if you have other coverage. Fill out your “Initial Enrollment

Questionnaire” (IEQ) at MyMedicare.gov to make sure your medical bills are paid

correctly and on time.

The IEQ asks if you have group health plan coverage through your work or a

family member’s work. Medicare uses your answers to help set up your file

and make sure your claims get paid correctly.

You can also complete your IEQ over the phone by calling the Coordination

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

1-800-318-8782.

Example: Harry is almost 65 and is getting ready to retire and join

Medicare. Harry’s wife Jane, 63, 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. 

After he gets a letter from Medicare with his username and password for

MyMedicare.gov, Harry goes to the Web site and fills out his IEQ. He

reports he has coverage through his wife’s employment. This insurance will

pay Harry’s claims first, and Medicare will pay Harry’s claims second.

What happens if my health coverage changes after I fill out the IEQ?

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

TTY users should call 1-800-318-8782. Give the following information:

• Your name

• The name and address of your health plan

• Your policy number 

• The date coverage was added, changed or stopped, and why

Tell your doctor and other health care providers about changes in your

coverage when you get care.
5

Section 1: When You Have Other Health Coverage

How Medicare Coordinates with Other Coverage (continued)

What if I have Medicare and more than one type of coverage?

Check your insurance policy—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 can get Medicare because of disability and is

covered by a large group health plan through his/her own current employer

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 due to End-Stage Renal Disease and is covered by a group

health plan

• When the domestic partner can get Medicare because of age and has group

health plan coverage through his/her current employer

When is Medicare a primary payer for domestic partners with group

health insurance coverage? 

If a domestic partner can get Medicare due to his/her age and has group

health plan coverage through his/her partner's current employer.

Where can I get more information about who pays first? 

Call your health insurance plan’s benefits administrator. You can also call the

Medicare Coordination of Benefits Contractor. 
6

Section 1: When You Have Other Health Coverage

Notes
7

Medicare and Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Medicare and Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . .8–10

Medicare and Group Health Plan Coverage After You Retire . . . . . . . .10–11

Medicare and Group Health Plan Coverage for People 

Who are Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Medicare and Group Health Plan Coverage for People with ESRD . . . . . 12

Medicare and No-Fault or Liability Insurance . . . . . . . . . . . . . . . . . . .13–15

Medicare and Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . .15–19

Medicare and Veterans’ Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19–20

Medicare and TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20–21

Medicare and the Federal Black Lung Benefits Program . . . . . . . . . . . .21–22

Medicare and COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22–23

2Section 2: Medicare and Other Types of Health Coverage
8

Section 2: Medicare and Other Types of Health Coverage

Words in

red are

defined

on pages

25–26.

Medicare and Medicaid

Medicaid (also called Medical Assistance) is a joint Federal and State

program that helps pay medical costs for certain people and families who

have limited income and resources and meet other requirements. Medicaid

never pays first for services covered by Medicare. It only pays after

Medicare, employer group health plans, and/or Medicare Supplement

Insurance (Medigap) policies have paid. 

Medicare and Group Health Plan Coverage

You have a number of important decisions to make when you turn 65:

should you join Medicare Part B, join a Medicare Prescription Drug Plan,

buy a Medigap policy, and/or keep employer or retiree coverage? 

By understanding your choices, you can avoid paying more than you need

to, and get coverage that meets your needs. 

Visit www.medicare.gov/find-a-plan to compare Medicare health and drug

plans in your area. You can also call your State Health Insurance Assistance

Program (SHIP). To get their phone number, visit

www.medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227).

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

Should I get group health plan coverage? 

Many employers and unions offer group health plan coverage to 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’re offered coverage under a group health plan,

you can choose to accept or reject the plan. 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 both of the following are true:

• You’re 65 or older and covered by a group health plan through your current

employer or the current employer of a spouse of any age

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

as Medicare (this means 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 health care

provider should bill Medicare for secondary payment. Medicare will look at

what your group health plan paid, and pay any additional costs up to the

Medicare-approved amounts as appropriate. You’ll have to pay whatever costs

Medicare or the group health plan doesn’t cover. 
9

Section 2: Medicare and Other Types of Health Coverage

Medicare and Group Health Plan Coverage (continued)

If your employer has less 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 less than 20 employees, you’ll need to find out from

your employer whether Medicare pays first or second. 

I’m in a Health Maintenance Organization (HMO) Plan or an

employer Preferred Provider Organization (PPO) Plan that pays first.

Who pays if I go outside the employer plan’s network? 

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

any payment from the plan or Medicare. Call your 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? 

Medicare pays its share for any Medicare-covered health care service you get if

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

don’t have coverage through an employed spouse. 

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 employer coverage when it’s first offered to you, you

might not get another chance to sign up. If you take the coverage but drop it

later, you may not be able to get it back. Also, you might be denied coverage

if your employer or your spouse’s employer generally offers retiree coverage

(see page 10) but you weren’t 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. 
10

Section 2: Medicare and Other Types of Health Coverage

Medicare and Group Health Plan Coverage (continued)

If I’m 65 or older and still working, what health benefits does my

employer have to offer me? 

Generally, employers with 20 or more employees must offer current

employees 65 and older the same health benefits, under the same conditions,

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

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

spouses under 65. 

Medicare and Group Health Plan Coverage After You Retire

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

It depends on the terms of your specific plan. Your employer or union or your

spouse’s employer or union might not offer any health coverage after you retire. 

If you can get group health plan coverage after you retire, it might have different

rules and might not work the same way with Medicare. 

What do I need to find out about retiree coverage? 

• Can I continue my employer coverage after I retire? Generally, when you

have retiree coverage from an employer or union, they manage this coverage.

Employers aren’t required to provide retiree coverage, and they can change

benefits or premiums, or even cancel coverage.

• What are the price and benefits of the retiree coverage, and does it include

coverage for my spouse? Your employer or union may offer retiree coverage

that limits 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. 

• What happens to my retiree coverage when I’m 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 join both Medicare Part A and

Medicare Part B to get full benefits from your retiree coverage.

• What effect will my continued coverage as a retiree have on both my

health coverage and my spouse’s health coverage? If you’re not sure how

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

materials, 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. You may want to talk to your State

Health Insurance Assistance Program (SHIP) for advice about whether to buy a

Medicare Supplement Insurance (Medigap) policy.

Words in

red are

defined

on pages

25–26.
11

Section 2: Medicare and Other Types of Health Coverage

Medicare and Group Health Plan Coverage After You Retire (continued)

How does retiree coverage compare with a Medicare Supplement Insurance

(Medigap) policy? 

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

similar to coverage under a Medigap policy. Retiree coverage isn’t the same

thing as a Medigap policy but, like a Medigap policy, it usually offers benefits

that fill in some of Medicare’s gaps in coverage, such as coinsurance and

deductibles. Sometimes retiree coverage includes extra benefits, like coverage for

extra days in the hospital. 

If I choose to buy a Medigap policy, when should I buy it? 

The best time is during your 6-month Medigap Open Enrollment period, because

you can buy any Medigap policy sold in your state, even if you have health

problems. This period automatically starts the month you’re 65 and enrolled in 

Part B, and once it’s over, you can’t get it again. 

Remember: You and your spouse would each have to buy 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

to view the booklet “Choosing a Medigap Policy: A Guide to Health Insurance for

People with Medicare.” To find and compare Medigap polices, visit

www.medicare.gov/find-a-plan, or call 1-800-MEDICARE (1-800-633-4227). 

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

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

my former employer. Who pays first? 

Generally, Medicare pays first for your health care bills and your group health plan

(retiree) coverage pays 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, Federal COBRA rules

may protect you if any other company within the same corporate organization still

offers a group health plan to its employees. That plan is required to offer you

COBRA continuation coverage. See pages 22–23. If you can’t get COBRA

continuation coverage, you may have the right to buy a Medigap policy even if

you’re no longer in your Medigap Open Enrollment Period.
12

Section 2: Medicare and Other Types of Health Coverage

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 you’re under age 65 or if you have Medicare because of a disability.

Sometimes employers with less than 100 employees join with other employers

to form a multi-employer plan. If at least 1 employer in the multi-employer

plan has 100 employees or more, Medicare pays second. 

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

group health plan. If you’re covered by a large group health plan because of

your current employment or the current employment of a family member,

Medicare pays second. A large group health plan can’t treat any plan member

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, so Mary’s group health plan

coverage pays first for Mary’s husband, and Medicare pays second.

Medicare and Group Health Plan Coverage for People with

End-Stage Renal Disease (ESRD)

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 in Medicare. 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. 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.
13

Section 2: Medicare and Other Types of Health Coverage

Medicare and No-Fault or Liability Insurance

What is no-fault insurance?

No-fault insurance pays for health care services you get because you get

injured or your property gets damaged in an accident, regardless of who is at

fault for causing the accident. 

Some types of no-fault insurance include:

• Automobile insurance

• Homeowners’ insurance

• Commercial insurance plans

What is liability insurance? 

Liability insurance protects against claims for negligence—inappropriate

action or inaction that causes someone to get injured or causes property

damage. 

Some types include:

• 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

lawyer should notify Medicare as soon as possible.

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.

If doctors or other providers are told you have a no-fault or liability

insurance claim, they must try to get paid 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 get back any

payments the primary payer should have made.
14

Section 2: Medicare and Other Types of Health Coverage

Words in

red are

defined

on pages

25–26.

Medicare and No-Fault or Liability Insurance (continued)

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

(continued) 

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 coverage related to the accident. Nancy tells the

hospital that her granddaughter has Med Pay coverage. Because this

coverage pays regardless of fault, it’s 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

no-fault insurance.

What’s a conditional payment? 

A conditional payment is a payment Medicare makes for services another

payer may be responsible for. Medicare makes this conditional payment 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, award, or other payment is made. 

Note: If Medicare makes a conditional payment for an item or service, and

you get a settlement, judgment, award, or other payment for that item or

service from an insurance company later, the conditional payment must be

repaid to Medicare. You’re responsible for making sure 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 Joan got. When a settlement is reached with the liability insurer,

Joan must make sure Medicare gets its money back for the conditional

payment.
15

Section 2: Medicare and Other Types of Health Coverage

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 who uses the information

you or your representative gives to the COBC to see Medicare gets repaid for

the conditional payments.

The recovery contractor will gather information about any conditional

payments Medicare made related to your pending settlement, judgment,

award, or other payment. Once a settlement, judgment, award, or other

payment 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 pays the same as it would if it were the only payer.

However, Medicare only pays for Medicare-covered services. You’re

responsible for your share of the bill, like coinsurance, a copayment or a

deductible, and for services Medicare doesn’t cover. 

Where can I get more information? 

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

COCB.

Medicare and Workers’ Compensation

What is workers’ compensation?

Workers’ compensation is a law or plan requiring employers to cover

employees who get sick or injured on the job. Workers’ compensation plans

cover most employees. If you don’t know whether you’re covered, ask your

employer, or contact your state workers' compensation division or

department. 
16

Section 2: Medicare and Other Types of Health Coverage

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 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, unless you get funds from a Workers’

Compensation Medicare Set-aside Arrangement (WCMSA)

following the settlement of a workers’ compensation case. See next

page for more information on WCMSAs.

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 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 with

workers’ compensation insurance. His doctor billed the state

workers’ compensation insurance for payment. Tom's doctor

didn't get paid within 120 days, so he billed Medicare and sent a

copy of Tom's workers’ compensation claim with the claim for

Medicare payment. Medicare made a conditional payment to the

doctor for the health care services Tom got. When a settlement is

reached with the state workers’ compensation agency, Tom must

make sure Medicare gets its money back for the conditional

payment.

Words in

red are

defined

on pages

25–26.
17

Section 2: Medicare and Other Types of Health Coverage

Medicare and Workers’ Compensation (continued) 

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, call the Medicare

Coordination of Benefits Contractor 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 with the

information you or your lawyer gave to the COBC. The recovery contractor

will gather information about any conditional payments Medicare made

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

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

contractor, who 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? 

You or your lawyer should contact the recovery contractor. 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 you already got.

When and why would I need a Workers’ Compensation Medicare 

Set-aside Arrangement (WCMSA)? 

If you settle your worker’s compensation claim, the settlement may provide for

funds to be set aside to pay for future medical and prescription drug expenses

related to your injury, illness or disease. When you have Medicare, ask your

workers’ compensation lawyer to set up a Workers’ Compensation Medicare

Set-aside Arrangement (WCMSA) for depositing these funds. 

The WCMSA ensures workers’ compensation funds are spent on expenses

otherwise covered by Medicare. In other words, workers’ compensation pays

before Medicare, even after a settlement. If you have a WCMSA as part of your

workers’ compensation settlement, you must be careful how you spend money

specifically set aside for Medicare.

You or your lawyer need to send your proposed WCMSA to the Medicare

Coordination of Benefits Contractor at:

CMS

c/o Coordination of Benefits Contractor

P.O. Box 33849

Detroit, Michigan 48232

Attention: WCMSA Proposal
18

Section 2: Medicare and Other Types of Health Coverage

Medicare and Workers’ Compensation (continued) 

How am I allowed to use the money in my Workers’ Compensation

Medicare Set-aside Arrangement (WCMSA) if I manage (self-administer)

the account?

Keep the following in mind if you manage your WCMSA (Note: workers’

compensation claims can be resolved by settlements, judgments, awards, or other

payments. The information below applies only to settlements.):

• Money placed in your WCMSA is for paying future medical and/or

prescription drug expenses related to your work injury or illness/disease that

otherwise would have been paid back by Medicare.

• You can’t use the WCMSA to pay for any other work injury, or any medical

items or services that Medicare doesn’t cover (like dental services).

• 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, call Medicare at 

1-800-MEDICARE (1-800-633-4227) for more information, before you use

any of the money that was placed in your WCMSA. TTY users should call 

1-877-486-2048.

• Keep records of your workers’ compensation-related medical and prescription

drug expenses. These records show what items and services you got and how

much money you spent on your work-related injury, illness, or disease. You

need these records to prove 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-related injury,

illness, or disease.

What if workers’ compensation denies payment?

If the state workers’ compensation insurance denies payment, and you give

Medicare proof that the claim was denied, Medicare will pay for Medicarecovered items and services as appropriate.

Example: 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 Medicare 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 must pay for anything Medicare doesn’t cover.
19

Section 2: Medicare and Other Types of Health Coverage

Medicare and Workers’ Compensation (continued) 

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.

Note: To get the Department of Veterans Affairs (VA) to pay for services, you

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

Are there any situations when both Medicare and the VA may 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 the VA doesn’t pay for.

Example: Bob, a veteran, goes to a non-VA hospital for a service authorized

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

services that the VA won’t pay for. Some of these services are Medicarecovered services. Medicare may pay for some of the non-VA authorized

services that Bob got. Bob will have to pay for services thata Medicare or the

VA doesn’t cover.
20

Section 2: Medicare and Other Types of Health Coverage

Medicare and Veterans’ Benefits (continued)

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

The VA may give “fee-basis ID cards” to certain veterans if the following

conditions apply:

• You have a service-connected disability.

• You’ll need medical services for an extended time period.

• There are no VA hospitals in your area.

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

or Medicare for these services.

If your doctor doesn’t accept the fee-basis ID card, you’ll need to file a claim

with the VA yourself. The VA will pay the approved amount either to you or

to your doctor.

Where can I get more information on Veterans’ benefits?

Visit www.medicare.gov, call your local VA office, or call the national VA

information number at 1-800-827-1000. TTY users should call 

1-800-829-4833. 

Medicare and TRICARE

What is TRICARE?

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

services members and their families that includes:

• TRICARE Prime

• TRICARE Extra

• TRICARE Standard

• TRICARE for Life (TFL)

What is TRICARE for Life (TFL)?

TFL provides expanded medical coverage to Medicare-eligible uniformed

services retirees 65 or older, to their eligible family members and survivors,

and to certain former spouses. You must have Medicare Part A and Medicare

Part B to get TFL benefits.

Words in

red are

defined

on pages

25–26.
21

Section 2: Medicare and Other Types of Health Coverage

Medicare and TRICARE (continued)

Can I have both Medicare and TRICARE?

Some people can have both Medicare and other types of TRICARE, such as:

• Dependents of active-duty service members who are allowed Medicare for

any reason

• People under 65 with Medicare Part A because of a disability or End-Stage

Renal Disease (ESRD) and with Medicare Part B

• People 65 or older who can get Medicare Part A and who join 

Medicare Part B

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 no

covered by Medicare that TRICARE covers. You pay the costs of services

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 health care

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

services you get from a Federal health care provider or other Federal agency.

Where can I get more information?

• Visit www.medicare.osd.mil

• Call the health benefits advisor at a military hospital or clinic. 

• Call 1-866-773-0404.

Medicare and the Federal Black Lung Benefits Program

I have Medicare and coverage under the Federal Black Lung Benefits

Program. Who pays first?

The Federal Black Lung Benefits 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 Benefits

Program. Your doctor or other health care provider should send all bills for

the diagnosis or treatment of black lung disease to: 

Federal Black Lung Program

P.O. Box 8302

London, Kentucky 40742-8302

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

and your doctor or health care provider should send your bills directly to

Medicare.

t
22

Section 2: Medicare and Other Types of Health Coverage

Medicare and the Federal Black Lung Benefits Program (continued)

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

Ask your doctor or other health care provider to send Medicare the bill. Ask them to

include a copy of the letter from the Federal Black Lung Benefits Program that says

why it won’t pay your bill.

Where can I get more information?

Call 1-800-638-7072 if you have questions about the Federal Black Lung Benefits

Program. 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 

What is COBRA?

COBRA is a Federal law that may allow you to temporarily keep employer or

union health coverage after the employment ends or after you lose coverage as

a dependent of the covered employee. 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 your coverage is ending and offering you the right to

elect COBRA continuation coverage. 

This coverage generally is offered for 18 months (or 36 months, in some

cases). If you don’t get a notice, but you find out your coverage has ended, or

if you get divorced, call the employer’s benefits administrator or the group

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

If you qualify for COBRA because the covered employee either died, lost

his/her job, or can now get Medicare, then the employer must tell the plan

administrator. Once the plan administer is notified, the plan must let you

know you have the right to choose COBRA coverage.

However, if you qualify for COBRA because you’ve become divorced or

legally separated (court issued separation decree) from the covered employee,

or if you were a dependent child or dependent adult child who is no longer a

dependent, then you or the covered employee needs to let the plan

administrator know about your change in situation within 60 days of the

change happening.
23

Section 2: Medicare and Other Types of Health Coverage

Medicare and COBRA (continued)

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

In general, the rules described on pages 8–11 that apply to group health plan

coverage also apply to COBRA continuation coverage. For example, if you or

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

first. 

If you have Medicare based on End-Stage Renal Disease (ESRD), COBRA

continuation coverage pays first. Medicare pays second to the extent COBRA

coverage overlaps the first 30 months of Medicare eligibility or entitlement based

on ESRD. 

Whether and when you should elect COBRA coverage can be a very

complicated decision. 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, so be aware that 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.

Where can I get more information 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. Visit

www.medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227) to

get their phone number. TTY users should call 1-877-486-2048.

• 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), visit the Department of Labor’s 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, call the Centers for Medicare & Medicaid Services (CMS) at 

1-877-267-2323 extension 61565.

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

Personnel Management’s Web site at www.opm.gov.
24

Section 2: Medicare and Other Types of Health Coverage

Notes
25

3

Section 3: Definitions

Claim—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 (ESRD)—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.

Health Care Provider—A person or organization that is licensed

to give health care. Doctors, nurses, and hospitals are examples

of health care providers.

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.
26

Section 3: Definitions

Medicaid—A joint Federal and state

program that helps with medical costs for

some people with limited income and

resources. Medicaid programs vary from

state to state, but most health care costs

are covered if you qualify for both

Medicare and Medicaid.

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)—

Coverage 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 (PartD)—

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.

Premium—The periodic payment to Medicare,

an insurance company, or a health care plan for

health or prescription drug coverage.

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.

TTY—A teletypewriter (TTY) is a

communication device used by people who

are deaf, hard-of-hearing, or have a severe

speech impairment. People who don’t have a

TTY can communicate with a TTY user

through a message relay center (MRC). An

MRC has TTY operators available to send

and interpret TTY messages.

Workers’ Compensation—A plan that

employers are required to have to cover

employees who get sick or injured on the job.
4

27

Section 4: Index

1-800-MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8, 11, 18, 23

Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 13

Black Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 21–22

Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3, 4, 13–19

COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 3, 11, 22–23

Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11, 15, 21, 25

Conditional Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 14–17

Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15, 25

Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11, 15, 21, 25

Denial of Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 12

End-Stage Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 12, 23, 25

Federal Black Lung Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 21–22

Group Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 4, 8–12, 22–23, 25

Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8–12

Health Care Provider . . . . . . . . . . . . . . . . . . . . . .1, 3, 4, 8, 9, 13, 21, 22, 25

Initial Enrollment Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Large Group Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 12

Liability Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 13–15

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2, 8, 26

Medicare Coordination of Benefits Contractor . . . 1, 4, 5, 15–17, 22–23, 26

Medicare Part A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 10, 11, 20, 21, 26

Medicare Part B . . . . . . . . . . . . . . . . . . . . . . . . . 1, 8, 10, 11, 20, 21, 23, 26

Medicare Prescription Drug Coverage (Part D) . . . . . . . . . . . . . 8, 17, 18, 26

Medicare Secondary Payer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 5

Medigap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8, 10, 11, 23, 26

Multi-Employer Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9, 12, 26

No-fault Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 13–15
28

Section 4: Index

Pre-existing Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10, 26

Primary Payer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 5, 13

Recovery Contractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15–17, 26

Retiree Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 8–11

State Health Insurance Assistance Program . . . . . . . . . . . . . . . . 8, 10, 23, 26

TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 20–21

TRICARE for Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Veterans’ Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3, 19–20

Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 15–19, 26

Workers’ Compensation Medicare Set-aside Arrangement . . . . . . 16–18, 26
29

Notes
30

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 November 2011

• ¿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.

• 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.