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Medicare Primary Rules

Sometimes people have more than one health care provider. In this situation, one of the health care providers is considered the primary provider and the other the secondary provider. When Medicare is involved, it is usually the primary provider, but there are situations when it is not. Specific rules determine when Medicare is not the primary provider. These rules apply when a person continues to carry health insurance past age 65, with COBRA; when a person is disabled; and when a person has end stage renal disease (ESRD).

  1. Insurance Beyond Age 65

    • If you or your spouse continue to work and carry health insurance, that provides you coverage beyond age 65. Medicare will be the primary payer if the company providing the insurance has fewer than 20 employees. If the company has 20 employees or more, the other insurance will be the primary payer. If you are not working or your other insurance is not through an employer, it will be retiree insurance (supplemental insurance), and Medicare is the primary payer.

    COBRA

    • If you enrolled in Medicare because of your age, a disability or end stage renal disease (ESRD) and had COBRA before enrolling, Medicare is the primary payer. If you had Medicare before being eligible for COBRA, Medicare is the primary payer. If you are under age 65, but are eligible for Medicare because of ESRD, COBRA is the primary payer during the 30-month coordination period. The coordination period begins the first month you would have qualified for Medicare regardless of whether you enroll or not.

    End Stage Renial Disease

    • When a person has ESRD and has a group health plan or a retiree plan, that plan is the primary payer during the coordination period. After the coordination period, Medicare is the primary payer. If there is no other insurance, Medicare is always the primary payer.

    Disabilities

    • When a person has Medicare because of a disability and also has insurance through a current employer, Medicare will be the primary payer if the company has fewer than 100 employees. If the employer has 100 or more employees, the other insurance will be the primary payer.

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