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
• cms.gov/Medicare-Learning-Network-MLN/  Medicare Secondary Payer
  • Manual 

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.

You cannot buy additional coverage through #Covered California
if you have premium-free Medicare Part A Hospital

Medicare complies with Health Care Reform, so you do NOT need to get a an Individual policy or a subsidized one from Covered CA.  It fact, it’s illegal for anyone to sell you a policy!  ^{Kaiser Health News * Covered CA Medicare Fact Sheet * Medicare.Gov Medicare & Market Place #11694  * CMS.Gov FAQ Medicare & Marketplace * HealthCare.Gov when – how to change from Covered CA to Medicare  * Social Security §1882  * Health Care.Gov}

NOTE: This information also applies to people younger than 65 whose benefits begin the first month they receive disability benefits because they have Amyotrophic Lateral Sclerosis (ALS), better known as Lou Gehrig’s Disease, and to people younger than 65 who have Medicare because of a disability and are receiving SSDI Social Security Disability Insurance.

There are a lot of ands, if or buts in this complex issue.  Please refer to the source material below.  There are some exceptions, but they are very complex.  Don’t even think of getting a 1/2 correct answer over the phone. If you have to pay for Part A Hospital, then are options, like subsided Covered CA Plans. Email us [email protected]

Video about Covered CA – if no Premium Free Part A – jump to 2:30  Medicare & the Marketplace (Covered CA

• Medicare Publication # 11694 Medicare & Covered CA
  • Covered CA Medicare Fact Sheet 
  • Medicare vs Covered CA – Publication 11694

    Selling Covered CA  Plans To Medicare Beneficiaries Will Be Illegal  Kff.org 

  • InsureMeKevin.com
  • Publication 02179 How Medicare works with other Insurance  Our webpage 

Sec. 1882. [42 U.S.C. 1395ss]

(3)(A)

(i) It is unlawful for a person to sell or issue to an individual entitled [no premium] to benefits under part A or enrolled under part B of this title (including an individual electing a Medicare+Choice plan [MAPD] under section 1851)—

(I) a health insurance policy with knowledge that the policy duplicates health benefits to which the individual is otherwise entitled under this title or title XIX,

(II) in the case of an individual not electing a Medicare+Choice plan, [aka MAPD Medicare Advantage] a medicare supplemental policy with knowledge that the individual is entitled to benefits under another medicare supplemental policy or in the case of an individual electing a Medicare+Choice plan, a medicare supplemental policy with knowledge that the policy duplicates health benefits to which the individual is otherwise entitled under the Medicare+Choice plan or under another medicare supplemental policy, or

(III) a health insurance policy (other than a medicare supplemental policy) with knowledge that the policy duplicates health benefits to which the individual is otherwise entitled, other than benefits to which the individual is entitled under a requirement of State or Federal law.

(ii) Whoever violates clause (i) shall be fined under title 18, United States Code, or imprisoned not more than 5 years, or both, and, in addition to or in lieu of such a criminal penalty, is subject to a civil money penalty of not to exceed $25,000 (or $15,000 in the case of a person other than the issuer of the policy) for each such prohibited act. ^{Sec. 1882. [42 U.S.C. 1395ss]} 

Our webpages that touch on this Issue:

• Part B – Doctors – How to sign up – Benefit
• Part B Late Enrollment Penalt
• End Stage Renal – Kidney Failure
• Age 65 – Tax Credits?
• Part A Hospital rules for zero premium
• Employer Plans vs Medicare – over or under 20 employees?