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.
We’ve also included the relevant pamphlets from Medicare.
- Dual Coverage # 02179
- Medicare as Secondary Payer
- Medicare website,
- Medicare’s Subrogation Right to collect from other insurance
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.
See also our page on dual coverage in general.
Medicare Secondary Payer Recovery Process
Click to Enlarge
Benefits Coordination & Recovery Center (BCRC)—
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. This company also acts on behalf of Medicare to obtain repayment when Medicare makes a conditional payment, and the other payer is determined to be primary
1-855-798-2627.
Medicare Dual Coverage
# 02179
Our Webpage on Medicare & Dual Coverage
Coordination of benefits –
two or more insurance plans
VIDEO
Employer obligation to report # of employees to Medicare
Explanation from Cal Broker Magazine Sept 2019
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
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- Individual & Family Direct *** Covered CA
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- Employer Group
Dual Coverage Questions from a website visitor
Answered in Interlineation
My wife (I have full authorization filed for disclosure) is 69 and coverage by traditional Medicare (A and B) and also has group health insurance under a group of less than 20 employees.
***Thus Medicare pays first.
She had an accident and fractured her teeth requiring implant and new porcelain/ceramic pontics.
***Thus Medicare would pay for an accident, but not routine dental.
Claims were submitted to BCBS of Florida who says we should have first submitted the claim to Medicare.
***That’s correct, as Medicare pays first, then your group plan picks up the rest.
I have already paid directly for the services.
We reside in Florida and there were two D.M.D.’s (Doctor of Dental Medicine – same as DDS) involved in providing the services.
What do you recommend?
***I suggest that you just send the bill to Medicare. Then resend to your group plan, once Medicare has paid.
(Also, when we look at my wife’s profile online
***Do you mean her Medicare profile? www.MyMedicare.Gov?
it doesn’t list the supplemental carrier at all. How to we correct that?
***Send me your password privately and I’ll figure it out. Medicare also has a customer service and live chat on the website. They should be able to help you.
I’m turning 65 and I have an individual plan that doesn’t have a co-ordination of benefits clause along with a Covered CA plan. I’ve been able to collect twice as the individual plan doesn’t have a co-ordination of benefits clause.
I’m turning 65, it appears that my individual plan, won’t duplicate benefits with Medicare.
Does that mean I can’t collect twice? Can I collect up to 100%?
Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan).
Ensures that the amount paid by plans in dual coverage situations does not exceed 100% of the total claim, to avoid duplicate payments. CMS.gov
noun: duplicate; plural noun: duplicates
/ˈd(y)o͞opləkət/Submit
1.
one of two or more identical things.
“books may be disposed of if they are duplicates” Google
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