If you have coverage besides Medicare or should have had Medicare – who pays?
Medicare #DualCoverage
Publication - 02179
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VIDEO how two plans coordinate and pay your claim.
- Medicare.Gov on how Medicare works with other insurance.
- Employer obligation to report # of employees to Medicare
- Explanation from Cal Broker Magazine Sept 2019
- Sample Small Employer Group Health Plan
- Medicare & Other Insurance CA Health Care Advocates Fact Sheet pdf
#Subrogation
Medicare's Right to collect from other Coverage
- You're Medicare Advantage plan has the right and responsibility to collect - subrogate for covered Medicare services for which Medicare is not the primary payer.
- According to CMS regulations at 42 CFR sections 422.108 and 423.462, Anthem MediBlue Access (PPO), as a Medicare Advantage organization, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any state laws. Anthem MediBlue Access (PPO) Evidence of Coverage
- Medi-Cal (for People with Medicare) – 04-19-23 Hi Cap CA Health Care Advocates
How are claims paid if you have #Medicare &
Other Insurance?
Dual Coverage?
If you have questions about how Medicare works with other coverage, you’ve come to the right page. Hopefully, we’ve or our links will answer all your questions on dual coverage here. If not, use the FAQs / Ask Us a Question feature below.
We’ve also included the relevant pamphlets from Medicare.
- Medicare Guide to Dual Coverage who pays first publication # 02179
- Medicare website, on dual coverage
- Medicare’s Subrogation Right to collect from other insurance
FAQ’s
I have Medicare and:
- I have Medicaid.
- I’m 65 or older and have group health plan coverage based on my current employment (or the current employment of a spouse of any age), and my employer has 20 or more employees.
- I’m under 65, entitled to Medicare because I have a disability (other than ESRD), I’m covered by a large group health plan because I or a family member is still working.
- I work for a small company that has a group health plan.
- I have a domestic partner with group health insurance coverage.
- I have declined or dropped employer-offered coverage.
- I’m retired, 65 or older and have group health plan coverage from my former employer.
- I’m retired, under 65 and disabled (other than by ESRD), and have group health plan coverage from my former employer.
- I have COBRA continuation coverage.
- I’m in a Health Maintenance Organization (HMO) Plan or an employer Preferred Provider Organization (PPO) Plan that pays first. Who pays first if I go outside the employer plan’s network?
- I get health care services from the Indian Health Service.
- I have more than one other type of insurance or coverage.
- I have TRICARE.
- I have Veterans’ benefits
- I have ESRD and group health plan coverage.
- I have coverage under the Federal Black Lung Program.
- I have a claim for no-fault or liability insurance.
- I filed a workers’ compensation claim.
If you still have questions, email us, * set a meeting, * ask us a question right on this page, you don’t have to even leave your name.
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Medicare Secondary Payer Recovery Process
Click to Enlarge
Benefits Coordination & Recovery Center (BCRC)—
The BENEFITS COORDINATION & RECOVERY CENTER (BCRC) 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.
BCRC acts on behalf of Medicare to obtain repayment when Medicare makes a conditional payment, and the other payer is determined to be primary – the one that pays 1st.
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Everything you want to know
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- Clear View to Medicare Patient Advocate.org - 36 pages
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#Understanding Medicare Advantage Plans (PDF) #12026
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