Table of contents
What is coordination of benefits? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1
Coordination of benefits � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1
How will Medicare know I have other coverage? � � � � � � � � � � � � � � � � � � � � � � � � � � 2
How does Medicare work with other types of coverage? � � � � � � � � � � � � � 3
Coverage from a group health insurance plan: � � � � � � � � � � � � � � � � � � � � � � � � � � � 4
Coverage from COBRA: � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7
Coverage from a federal program: � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 8
If you have ESRD or a disability: � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11
If you have a dierent source of coverage: � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 14
Section 1: What is coordination of benefits? 1
Section 1:
What is coordination of
benefits?
If you have Medicare and other health insurance, each type of coverage is called a
“payer�” When there’s more than one payer, the order of payment is called “coordination
of benefits�” Coordination of benefits rules determine who pays first� The same
coordination of benefits rules apply whether you have Original Medicare, Medicare
Advantage (Part C) (with or without drug coverage), or Medicare drug coverage
(Part D)�
Section 1: What is coordination of benefits?2
The “primary payer” pays what it owes on your bills first, up to the limits of its
coverage, then you or your healthcare provider sends the balance to the “secondary
payer” (supplemental payer)� If the secondary payer doesn’t cover the remaining
balance, you may be responsible for the rest of the costs� The type of payer and other
factors determine how the coordination of benefit rules apply� Examples of payer
types discussed in this booklet are:
• Group health plans for workers or retirees
• COBRA plans
• Federal programs like Veterans benefits, TRICARE, Indian Health Service, Federal
Black Lung Program, and Medicaid
• Non-group health plans like liability insurance, no-fault insurance, and workers’
compensation
Section 2 of this booklet describes in more detail how each payer and other factors
determine who pays first� Whether Medicare pays first depends on your situation�
You can find common situations in section 2, but this booklet doesn’t cover every
situation� Be sure to tell your providers if you have health coverage in addition to
Medicare� This will help them send your bills to the correct payer and avoid delays�
If your group health plan or retiree coverage is the secondary payer, you may need to
sign up for Medicare Part B before they’ll pay� If you have questions about who pays
first, or if your coverage changes, call the Benefits Coordination & Recovery Center at
1-855-798-2627 (TTY: 1-855-797-2627), or visit Medicare.gov/supplements-other-
insurance/how-medicare-works-with-other-insurance�
How will Medicare know I have other coverage?
Medicare doesn’t automatically know if you have other coverage� However, insurers
must notify Medicare when they’re responsible for paying first on your medical
claims� In some cases, your health care provider, employer, or insurer may ask you
questions about your current coverage so they can report that information to
Medicare� If you’re in a Medicare Advantage Plan (Part C) or Medicare drug plan
(Part D), you’re responsible for responding to questions from your plan about your
other coverage�
Example: Harry recently turned 65 and is enrolled in Medicare� He works for a
company with 20 or more employees, and he has coverage through his employer’s
group health plan� Since Harry is still currently working, the insurer will report Harry’s
group health plan insurance information to Medicare so that Medicare knows to pay
Harry’s claims second�
Section 2: How does Medicare work with other types of coverage? 3
Section 2:
How does Medicare work
with other types of
coverage?
Coordination of benefits depends on which insurance is considered “primary” and
which is “secondary�” The insurance that pays first (primary payer) pays up to the limits
of its coverage� The insurance that pays second (secondary payer) only pays if there
are costs the primary insurance didn’t cover and that payer covers the service�
Some of the factors that influence who pays first are:
• The type of coverage you have
• Your age
• If you’re retired
• If you’re disabled
Note: For the situations described in this section, “spouse” includes both opposite-sex
and same-sex marriages where you’re:
Section 2: How does Medicare work with other types of coverage?4
• Entitled to Medicare as a spouse based on Social Security’s rules; and
• Legally married in a U�S� jurisdiction that recognizes the marriage—including one of
the 50 states, the District of Columbia, or a U�S� territory (or a foreign country, so
long as that marriage would also be recognized by a U�S� jurisdiction)�
An employer, insurer, third party administrator, group health plan, or other plan sponsor
may choose to have a more inclusive definition of spouse than what’s described above�
If that happens, the plan may (but isn’t required to) pay first for someone it considers
a spouse under its definition� Contact your employer or insurer if you have a question
about its definition of “spouse” and how it pays claims for you and your spouse as
applicable�
Coverage from a group health insurance plan
Many employers, employee organizations and unions oer group health plan coverage
to current employees or retirees� You may also get group health plan coverage through
the employer of your spouse or another family member (like a domestic partner,
parent, son, daughter, or grandchild)� Generally, a group health plan gives health
coverage to employees and their families�
If you have Federal Employees Health Benefits (FEHB) Program coverage, your
coverage works the same as it does for other group health plans�
If you have coverage from a group health insurance plan through your (or a spouse or
family member’s) current employer, who pays first depends on things like your age and
the number of employees in the company (or multi-employer health insurance group)�
I’m 65 or older and have group health plan coverage based on
my (or my spouse’s) current employment status (including self-
employment). Who pays first?
• My (or my spouse’s) employer has 20 or more employees (or has less than 20
employees, but is part of a multi-employer group where at least one company has
20 or more employees):
– Generally, your (or your spouse’s) group health plan pays first and Medicare pays
second� If the group health plan didn’t pay your entire bill, your provider should
send the bill to Medicare for secondary payment� You may have to pay any costs
Medicare or the group health plan doesn’t cover�
– Employers with 20 or more employees must oer current employees age 65
and older the same health benefits under the same conditions that they oer
employees under 65� If the employer oers coverage to spouses, it must oer the
same coverage to spouses 65 and older that it oers to spouses under 65�
Note: Your plan may ask for an “exception” to opt out of a multi-employer group
health plan� Check with your plan first and ask whether it will pay first or second for
your claims�
• My (or my spouse’s) employer has fewer than 20 employees (and isn’t part of a
multi-employer group where at least one company has 20 or more employees):
– Medicare pays first and the group health plan pays second�
Section 2: How does Medicare work with other types of coverage? 5
What happens if I don’t accept my (or my spouse’s) employer coverage?
Medicare pays its share for any of your Medicare-covered health care services, even if
you don’t take group health plan coverage from your or your spouse’s employer�
Remember: If you don’t take employer coverage when it’s first oered 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
(or your spouse’s) employer generally oers retiree coverage, but you weren’t in
the plan while you or your spouse were still working� Call your employer’s benefits
administrator for more information before you decide�
I’m 65 or older, still working, and in a Health Maintenance
Organization (HMO) Plan or an employer Preferred Provider
Organization (PPO) Plan that pays first. Who pays if I get services
outside the employer plan’s network?
If you get care outside your employer plan’s network, it’s possible that neither the
plan nor Medicare will pay� Call your group health plan before you go outside the
network to find out if it will cover the service�
I’m 65 or older, retired, and have retiree coverage from a group
health insurance plan through my (or my spouse’s) former employer.
Who pays first?
Medicare pays first, and your (or your spouse’s) group health plan pays second�
What about drug coverage?
• Check with your benefits administrator before you add Medicare drug coverage�
If you have employer or union coverage and add Medicare drug coverage, you may
lose your employer or union benefits (including any non-drug health coverage)
for yourself and/or your spouse or dependents if you sign up for Medicare drug
coverage� If this happens, you may not be able to get your employer or union
coverage back� This is true even if you get Extra Help� If you have retiree coverage,
check with your benefits administrator to find out if you’ll lose retiree benefits
(including any non-drug health coverage) for yourself and/or your spouse or
dependents if you add Medicare drug coverage�
• If you have drug coverage through your current or former employer, your
employer or union will notify you each year to let you know if your drug coverage
is creditable� Keep this information for your records�
• If your drug coverage is creditable, you can wait to join a Medicare drug plan and
not pay a penalty if you don’t go without creditable prescription drug coverage for
63 days�
• Federal Employee Health Benefits Program (FEHB) plans include creditable
prescription drug coverage, so you don’t need to get Medicare drug coverage�
However, if you decide to get Medicare drug coverage, you can keep your FEHB
plan, and in most cases, Medicare will pay first�
Section 2: How does Medicare work with other types of coverage?6
What happens to my group health plan coverage after I retire?
It depends on the terms of your specific plan� Your or your spouse’s employer or
union might not oer any health coverage after you retire� Also, if you can get group
health plan coverage after you retire, the plan might have dierent rules and might
not work the same way with Medicare� Call your employer’s benefits administrator for
more information�
How does retiree coverage work with Medicare?
Your former employer or union manages any retiree coverage you have with that
organization� Employers and unions aren’t required to oer retiree coverage, and they
can change benefits or premiums, or even cancel coverage at any time�
If your former employer oers retiree coverage, the coverage might not pay your
medical costs for any period when you were eligible for Medicare but didn’t sign up
for it� When you become eligible for Medicare, you may need to sign up for both
Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) to get
full benefits from your retiree coverage�
Your former employer or union may oer limited retiree coverage� For example, it
might only provide “stop loss” coverage, which starts paying only when your out-of-
pocket costs reach a certain amount�
If you aren’t sure how your retiree coverage works with Medicare, get a copy of
your plan’s benefit materials, or review the summary plan description your former
employer or union gave you� Call your former employer’s benefits administrator for
more information about how the retiree plan pays when you have Medicare�
Coverage from COBRA
What’s COBRA?
COBRA is a federal law that may allow you to temporarily keep employer or union
health coverage after your 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 states require insurance companies covering employers with fewer than 20
employees to let you keep your employer or union coverage for a period of time�
If I have Medicare and COBRA continuation coverage, who pays first?
If you have Medicare because you’re 65 or over, or because you have a disability,
Medicare pays first�
If you’re eligible for or entitled to Medicare because of End-Stage Renal Disease
(ESRD), COBRA pays first, and Medicare pays second during a coordination period
that lasts up to 30 months after you’re first eligible for ESRD Medicare� After the
coordination period ends, Medicare pays first�
Section 2: How does Medicare work with other types of coverage? 7
Coverage from COBRA (continued)
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 oers
its employees a group health plan� That plan may be required to oer you COBRA
continuation coverage� If you can’t get COBRA continuation coverage, you may have
the right to buy a Medigap policy even if your Medigap Open Enrollment Period is
over� Contact your State Health Insurance Assistance Program (SHIP) to find out if
you can still buy a Medigap policy� To get the phone number for your local SHIP, visit
shiphelp.org, or call 1-800-MEDICARE� TTY users can call 1-877-486-2048�
What about drug coverage?
There may be reasons why you should take Medicare drug coverage instead of, or in
addition to, COBRA� If you take COBRA and it includes creditable prescription drug
coverage, you’ll have a Special Enrollment Period to join a Medicare drug plan without
a penalty when COBRA ends�
What else do I need to know?
Deciding if and when you should elect COBRA coverage can be very complicated�
When you lose employer coverage and you have Medicare, you need to be aware of
your COBRA election period, your Medicare Part B (Medical Insurance) enrollment
period, and your Medigap Open Enrollment Period� Each of these periods may have
dierent deadlines, and those deadlines might overlap� You should be aware that
what you decide about one coverage type (COBRA, Medicare Part B, and Medigap)
might cause you to lose rights under another�
Before you elect COBRA coverage, you can talk with your SHIP counselor about
Medicare Part B and Medicare Supplement Insurance (Medigap)� To get the phone
number for your state’s SHIP, visit shiphelp.org, or call 1-800-MEDICARE
(1-800-633-4227)� TTY users can call 1-877-486-2048�
Section 2: How does Medicare work with other types of coverage?8
Coverage from a federal program
If I have Medicare and Veterans, benefits, who pays first?
If you have (or can get) both Medicare and Veterans’ benefits, you can get coverage
under either program� However, Medicare doesn’t pay for any care that you get at
a U.S. Department of Veterans Aairs (VA) facility� Generally, Medicare and the VA
can’t pay for the same items or services� Each time you get health care or visit a
provider, you’ll have to choose which benefit to use�
Medicare pays for Medicare-covered items and services� The VA pays for VA-
authorized items or services in a VA or (authorized) non-VA facility�
What about drug coverage?
You may be able to get drug coverage through the VA program� You may also join a
Medicare drug plan, but if you do:
• You can’t use both types of coverage for the same drug at the same time�
• You won’t be able to use the Department of Veteran Aairs’ “Meds by Mail”
program�
What else do I need to know?
If the VA authorizes services in a non-VA hospital but didn’t authorize all the services
you get during your hospital stay, then Medicare may pay for the Medicare-covered
services the VA didn’t authorize�
If the doctor accepts you as a patient, and bills the VA for VA-authorized 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�
Visit VA.gov, call your local VA oce, or call the national VA information number at
1-800-827-1000� TTY users can call 1-800-829-4833�
Section 2: How does Medicare work with other types of coverage? 9
I have Medicare and TRICARE. Who pays first?
If you’re on active duty and have Medicare, TRICARE pays first for Medicare-covered
services or items, and Medicare pays second�
If you aren’t on active duty, Medicare pays first for Medicare-covered services, and
TRICARE may pay second�
If you get items or services from a military hospital or clinic, or any other federal
health care provider, TRICARE pays the bills� Medicare usually doesn’t pay for
services you get from a federal health care provider or other federal agency�
TRICARE For Life (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 (Hospital Insurance)
and Medicare Part B (Medical Insurance) to get TFL benefits� Visit tricare.mil/tfl, or
call 1-866-773-0404 to learn more� TTY users can call 1-866-773-0405�
What about drug coverage?
Most people with TRICARE who are entitled to Medicare Part A must also have
Medicare Part B to keep their TRICARE drug benefits� If you have TRICARE, you don’t
need to join a Medicare drug plan� However, if you do, your Medicare drug plan pays
first, and TRICARE pays second�
If you join a Medicare drug plan, TRICARE and your plan may coordinate their
benefits if your plan’s network pharmacy is also a TRICARE network pharmacy�
For more information, visit tricare�mil, or call the TRICARE Pharmacy Program
1-877-363-1303� TTY users can call 1-877-540-6261�
I have Medicare and get care from Indian Health Services (IHS) or an
IHS provider. Who pays first?
Generally, Medicare pays first for your health care bills, before the Indian Health
Service (IHS) delivery system, which is comprised of health facilities operated by
IHS, a Tribe or Tribal organization, or an urban Indian organization� However, these
conditions apply:
• If you have non-tribal group health plan coverage through an employer, the non-
tribal group health plan pays first, and Medicare pays second if:
– The employer has 20 or more employees, or
– The employer has fewer than 20 employees, but is part of a multi-employer
group where at least one employer has 20 or more employees
Section 2: How does Medicare work with other types of coverage?10
• If you have non-tribal group health plan coverage through an employer who has
fewer than 20 employees, Medicare pays first, and the non-tribal group health plan
pays second�
• If you have a health insurance through a tribal health plan, Medicare pays first and
the tribal health plan pays second�
What about drug coverage?
Many Indian health facilities participate in the Medicare drug program� If you get
prescription drugs through an Indian health facility, you’ll continue to get them at no
cost to you, and your coverage won’t be interrupted� Talk to your local Indian health
benefits coordinator who can help you choose a plan that meets your needs and tell
you how Medicare works with the Indian health care system�
I have Medicare and coverage under the Federal Black Lung Program.
Who pays first?
For any health care, including drugs, related to black lung disease, the Federal Black
Lung Program pays first as long as the program covers the service� Medicare won’t
pay for doctor or hospital services or drugs covered under the Federal Black Lung
Program�
Your 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 that isn’t related to black lung disease, Medicare pays first, and
your doctor or health care provider should send your bills directly to Medicare� If the
Federal Black Lung Program won’t pay your bill, ask your doctor or other health care
provider to send Medicare the bill� Also ask them to include a copy of the letter from
the Federal Black Lung Program that says why it won’t pay your bill�
Call 1-800-638-7072 if you have questions about the Federal Black Lung Program�
Call the Benefits Coordination & Recovery Center toll-free at 1-855-798-2627 if you
have questions about who pays first� TTY users can call 1-855-797-2627�
I have Medicare and Medicaid. Who pays first?
Most health care costs are covered if you qualify for both Medicare and Medicaid�
Medicaid never pays first for services Medicare covers� It only pays after Medicare has
paid� In rare cases where there’s other coverage besides Medicare, Medicaid pays after
the other coverage has paid�
Section 2: How does Medicare work with other types of coverage? 11
What about drug coverage?
Medicare covers your drug costs� You’ll need to join a separate Medicare drug plan
or a Medicare health plan with drug coverage for Medicare to pay for your drugs�
Medicaid can pay for a limited number of drugs that that are excluded from Medicare
drug coverage�
If you have full Medicaid coverage, you automatically qualify for Extra Help with your
Medicare drug coverage costs� If you don’t join a drug plan on your own, Medicare
will enroll you in one� Visit Medicare.gov/basics/costs/help/drug-costs for more
information on how Extra Help works
In most cases, you’ll pay a small amount for your covered drugs:
• If you have full coverage from Medicaid and live in a nursing home, you pay
nothing for covered prescription drugs�
• If you have full coverage from Medicaid and live at home or in an assisted living or
adult living facility, you’ll pay a small copayment for each drug�
Visit Medicaid.gov/about-us/beneficiary-resources/index.html#statemenu, or
call 1-800-MEDICARE (1-800-633-4227) to get the phone number for your state’s
Medicaid oce�
Medicare coverage because of End-Stage Renal Disease
(ESRD) or a disability:
Who pays first depends on things like:
• Your age
• Your disability
• How long you’ve gotten disability benefits
• Your other health plan coverage
I have Medicare because of ESRD and have group health plan
(including retiree) coverage (or coverage from a spouse or family
member). Who pays first?
Once you become eligible for Medicare because of permanent kidney failure, there
will be a 30-month coordination period� During this time, your group or retiree health
plan will continue to pay first for your health care bills, regardless of:
• The employer’s number of employees
• Whether you’re currently employed or retired
• Whether your group or retiree plan says its policy is to pay second to Medicare, or
otherwise rejects or limits its payments to people with Medicare
Section 2: How does Medicare work with other types of coverage?12
During your 30-month coordination period, if your plan doesn’t pay for covered
services in full, Medicare may pay second for all Medicare-covered items and services,
not just ones for the treatment of ESRD� Check with your plan if you’re not sure if it
will pay for covered services in full�
After the coordination period ends, Medicare pays first and the group health plan (or
retiree coverage) pays second�
Tell your health care provider if you have group or retiree health plan coverage so
they bill your services correctly� Your group or retiree health plan coverage may
still pay for services that Medicare doesn’t cover� Check with your plan’s benefits
administrator for more information�
I got Medicare when I turned 65 (or because of a disability other
than ESRD). I also have group health plan coverage (including
retiree coverage or coverage from a spouse or family member). Now
I have ESRD. Who pays first?
Whichever coverage paid first when you became eligible for Medicare because of
your age or non-ESRD disability continues to pay first when you become eligible
because of ESRD�
I have Medicare because of ESRD and COBRA coverage. Who pays
first?
COBRA pays first and Medicare pays second during the coordination period that lasts
up to 30 months after you’re first eligible for ESRD Medicare� After the coordination
period ends, Medicare pays first�
I have Medicare because of a disability (and am under 65) and group
health coverage. Who pays first?
Who pays first depends on if your group health coverage comes from your (or
a spouse or family member’s) current or former employer and the size of that
employer�
• I have Medicare because of a disability (and am under 65), and I have coverage
from a former employer.
In this case, Medicare pays first because the employer coverage isn’t based on
active employment�
Note: Retiree coverage might not pay your medical costs during any period when
you were eligible for Medicare but didn’t sign up for it� When you become eligible
for Medicare, you’ll need to sign up for both Medicare Part A and Medicare Part B
to get full benefits from your retiree coverage�
Check with your retiree coverage to find out if you’ll lose retiree benefits (including
any non-drug health coverage) for yourself and/or your spouse or dependents if
you get Medicare drug coverage�
Section 2: How does Medicare work with other types of coverage? 13
• I have Medicare because of a disability (and am under 65). I also have coverage
from my (or a spouse or family member’s) current employer.
If that employer has either 100 or more employees or has fewer than 100 employees
but is part of a multi-employer group where one or more companies has at least 100
employees, the group health plan pays first, and Medicare pays second�
Example: Mary works full-time for a company that 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�
Note: Health plans oered by employers with 100 or more employees are also
called “large group health plans�” They can’t treat any plan member dierently
because they’re disabled and have Medicare�
If that employer has fewer than 100 employees and isn’t part of a multi-employer
group plan (where one or more companies has 100 or more employees), then
Medicare pays first, and the group health plan pays second�
I have Medicare because of disability (and am under 65). I also get
disability benefits from either the Social Security Administration or
Railroad Retirement Board. Who pays first?
If you have been receiving benefits less than 24 months, you aren’t yet entitled to
Medicare, and your group health plan is your only payer� When you have gotten
disability benefits for 24 months, you qualify for Medicare, and who pays first will be
determined by your group health coverage�
Note: There’s no 24-month waiting period for people with Amyotrophic Lateral
Sclerosis (ALS), also known as Lou Gehrig’s disease�
Section 2: How does Medicare work with other types of coverage?14
I have Medicare because of a disability (and am under 65). I also
have retiree group health plan coverage through my former
employer. Who pays first?
If you aren’t currently employed, Medicare pays first for your health care bills and
your retiree group health plan coverage pays second�
Retiree coverage might not pay your medical costs during any period when you were
eligible for Medicare but didn’t sign up for it� When you become eligible for Medicare,
you’ll need to sign up for both Medicare Part A and Medicare Part B to get full
benefits from your retiree coverage�
Check with your retiree coverage to find out if you’ll lose retiree benefits (including
any non-drug health coverage) for yourself and/or your spouse or dependents if you
get Medicare drug coverage�
Coverage from a different source
No-Fault, Liability, or Workers’ Compensation Accident or Injury
Claims
What’s no-fault insurance?
No-fault insurance may pay for health care services you get if you’re injured or your
property gets damaged in an accident, regardless of who’s at fault for causing the
accident� Some types of no-fault insurance include:
• Automobile plans
• Homeowners’ plans
• Commercial insurance plans
Your no-fault insurance pays first, and Medicare pays second for health care services
related to the accident or injury�
Section 2: How does Medicare work with other types of coverage? 15
What’s liability insurance?
Liability insurance (including self-insurance) protects individuals against claims
for things like negligence or other types of potential wrongdoing (for example,
inappropriate action or inaction that causes someone to get injured or causes
property damage)�
Some types of liability insurance include:
• Homeowners’
• Automobile
• Product
• Malpractice
• Uninsured motorist
• Underinsured motorist
If you have a liability insurance claim for your medical expenses, you or your lawyer
should notify Medicare as soon as possible�
Your liability insurance pays first and Medicare pays second for health care services
related to the accident or injury�
If doctors or other providers are told you have a no-fault insurance or liability
insurance claim, they must try to get paid from the insurance company before billing
Medicare� If your accident or injury is an open ongoing responsibility medicals case,
then the liability or no-fault insurance must pay first� However, if your liability or no-
fault case doesn’t receive ongoing responsibility for medicals, then processing your
bill 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 will recover
the payment after a settlement, judgment, award, or other payment on the claim has
been made by the liability insurance�
What else do I need to know?
If the no-fault or liability insurance denies your medical bill or is found not liable for
payment, Medicare pays first, but only for Medicare-covered services� You’re still
responsible for your share of the bill (like coinsurance, a deductible or copayment)
and for the cost of services Medicare doesn’t cover�
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 emergency room, the hospital asks Nancy 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 the no-fault insurance doesn’t pay for some Medicare-covered services�
Section 2: How does Medicare work with other types of coverage?16
What’s workers’ compensation?
Workers’ compensation is a law or plan requiring employers to give benefits to most
employees who get sick or injured on the job� To find out if you’re covered, talk to
your employer, or contact your state workers’ compensation division or department�
Workers’ compensation pays first for items, including drugs, or services related to the
workers’ compensation claim�
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 doctor or other provider bills for a work-
related illness or injury and when the workers’ compensation insurance (a private
insurance carrier or a state fund) decides if it should pay the bill�
Medicare can’t pay for items or services that workers’ compensation will pay for
promptly or if the claim falls under an open ongoing responsibility for medicals
case, or there is an open Workers’ Compensation Medicare Set-aside Arrangement�
Generally, these include items or services that Workers’ Compensation Medicare Set-
aside Arrangement pays within 120 days of the date you received the service or the
date of your inpatient hospital discharge (if applicable), whichever is earlier�
Medicare may make a conditional payment if the workers’ compensation insurance
company denies payment for your medical bills, pending a review of your claim�
Note: This isn’t the same situation as when your workers’ compensation case has
been settled and you’re using funds from your Workers’ Compensation Medicare
Set-aside Arrangement to pay for your medical care� The conditional payment rules
don’t apply to an open and active ongoing responsibility for medicals case� They
also don’t apply to open Workers’ Compensation Medicare Set-aside Arrangement,
accident, and injury cases�
Example: Tom was injured at work� He filed a workers’ compensation claim� His
doctor billed the state workers’ compensation agency for payment, but she didn’t
get paid within 120 days, so she billed Medicare for a conditional payment� Medicare
made a conditional payment to Tom’s doctor for Tom’s health care services� If Tom
eventually gets a settlement, judgment, award, or other payment from the state
workers’ compensation agency, it’s Tom’s responsibility to make sure Medicare gets
repaid for the conditional payment�
What else do I need to know?
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 Benefits Coordination & Recovery Center
toll-free at 1-855-798-2627 as soon as you file your workers’ compensation claim�
TTY users can call 1-855-797-2627�
Section 2: How does Medicare work with other types of coverage? 17
What if workers’ compensation denies payment?
If workers’ compensation insurance denies payment, and you give Medicare proof
of the claim’s denial, Medicare may pay for Medicare-covered items and services as
appropriate� Medicare cannot pay, however, if you have a Workers’ Compensation
Medicare Set-aside Arrangement that has contributed funds towards your future
workers’ compensation-related health care needs, unless all of those funds have been
used to pay for medical care� Medicare can’t pay for accident related claims if you
have an open ongoing responsibility for medicals case related to this accident or
injury�
Can workers’ compensation decide to pay only part of my entire bill?
Yes, 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�
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�
My workers’ compensation claim is getting ready to settle. What happens next?
If you settle your workers’ compensation claim, you can volunteer to put some of
the settlement money in a Workers’ Compensation Medicare Set-aside Arrangement,
to pay for future medical care related to your work injury or illness� In many cases,
before reaching a settlement, the workers’ compensation agency will ask Medicare
to review certain medical documentation and approve an amount that can be put in
a Workers’ Compensation Medicare Set-aside Arrangement to pay for future medical
care, including drugs�
You must use any funds in your arrangement to pay for related medical care,
including drugs, before Medicare will begin paying for related care� Visit go.cms.gov/
WCMSASelfAdm to learn more about Workers’ Compensation Medicare Set-aside
Arrangements�
What if I have a Medicare-approved Workers’ Compensation Medicare Set-aside
Arrangement amount?
You must:
• Only use money from your arrangement to pay for future medical expenses,
including drugs, related to your work injury or illness that otherwise would’ve been
paid by Medicare�
• Use funds from the arrangement to pay for future medical expenses, including
drugs, even if you’re enrolled in a Medicare Advantage Plan�
• Use money from your Workers’ Compensation Medicare Set-aside Arrangement
to pay for drugs that are related to your work illness or injury, even if you are
enrolled in a Medicare drug plan (including a Medicare Advantage Plan with drug
coverage)�
Section 2: How does Medicare work with other types of coverage?18
You can’t use money from your arrangement to pay for any other work-related injury
or illness, or for any medical items or services that Medicare doesn’t cover (like dental
services)� You must spend all of your money from the arrangement on appropriate
related medical expenses before Medicare (either Original Medicare or Medicare
Advantage) will pay for any Medicare-covered medical expenses or drugs related to
your workers’ compensation claim�
Before using any of the funds from your arrangement, you should become familiar
with the types of services Medicare covers by visiting Medicare.gov or calling
1-800-MEDICARE (1-800-633-4227)� TTY users can call 1-877-486-2048�
Keep detailed records of your workers’ compensation-related medical expenses,
including drug expenses� These records should show what items and services you
got and how much money you spent on your work-related injury or illness� You’ll
need these records to prove you used the money from your arrangement to pay your
workers’ compensation-related medical expenses�
Visit go.cms.gov/WCMSASelfAdm to learn more about managing your Workers’
Compensation Medicare Set-aside Arrangement�
Conditional Payments
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 by the responsible person or payer� If you get a settlement,
judgment, award, or other payment, you are responsible for repaying Medicare for the
conditional payment�
When does Medicare make conditional payments?
Medicare may make a conditional payment if the liability, no-fault, or workers’
compensation insurance company doesn’t pay the claim promptly (usually within
120 days)� Medicare may recover any payments the primary payer should’ve made�
Your doctor should bill the accident or injury insurer first if he/she wants to receive
payment quicker� However, if the insurer denies the claim, the insurer must send the
reason for denial to your doctor� Then your doctor must send the denial to Medicare
so Medicare can review the claim to determine whether a Medicare payment can be
made before the 120 day period�
Note: Conditional payments are only made when there is no open Workers’
Compensation Medicare Set-aside Arrangement ongoing responsibility for medicals
case for a beneficiary, but Medicare is still receiving accident or injury related claims�
Section 2: How does Medicare work with other types of coverage? 19
How does Medicare recover conditional payments?
If Medicare makes a conditional payment for your liability, no-fault, or workers’
compensation related claim, and you or your representative haven’t reported your
settlement, judgment, award, or other payment to Medicare, call the Benefits
Coordination & Recovery Center at 1-855-798-2627 (TTY: 1-855-797-2627)� The
Benefits Coordination & Recovery Center:
• Gathers information about conditional payments Medicare makes�
• Calculates the final amount owed (if any) on your recovery case�
• Sends you a letter asking for repayment�
How do I make sure that Medicare gets repaid for the conditional payment?
If a conditional payment is made for a liability, no-fault, or workers’ compensation
related claim, you’re responsible for making sure Medicare gets repaid from any
settlement, judgment, award, or other payment you have received�
If you or your provider files a liability, no-fault or workers’ compensation claim and
Medicare makes a conditional payment for medical claims, you or your lawyer should
report the claim and payment by calling the Benefits Coordination & Recovery Center
toll-free at 1-855-798-2627� TTY users can call 1-855-797-2627�
The Benefits Coordination & Recovery Center will gather information about any
conditional payments for medical claims Medicare made related to your liability, no-fault,
or workers’ compensation claim� If you get a settlement, judgment, award, or other
payment, you or your lawyer should call the Benefits Coordination & Recovery Center�
If you have Original Medicare, the Benefits Coordination & Recovery Center will
calculate the final repayment amount (if any) on your case and send you a letter
requesting repayment� If your pending workers’ compensation claim is eventually
abandoned or dismissed, you or your lawyer should contact the Benefits Coordination
& Recovery Center with that information�
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 insurance company for
Joan’s health care services� 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 Joan’s health care services� When a settlement
is reached with the other driver’s insurance company, Joan must make sure Medicare
gets repaid for the conditional payment�
Example: Bob has a heart attack� Medicare pays for Bob’s medical care for his heart
attack and his recovery� Bob later learns that one of his prescription medications may
have triggered his heart attack� He’s part of a class action lawsuit against the company
that makes the medication, and he gets a settlement� Bob must make sure that
Medicare gets repaid for any conditional payments it made for him that are related to
his settlement�
Section 2: How does Medicare work with other types of coverage?20
What if Medicare pays for a claim that should have been paid for by my Workers’
Compensation Medicare Set-aside Arrangement?
Medicare may pay for medical or drug claims before knowing that the claims are
related to your workers’ compensation settlement� When this occurs, Medicare must
be repaid from the Workers’, Compensation Medicare Set-aside Arrangement� If you
have Original Medicare, the Benefits Coordination & Recovery Center will investigate
claims and request repayment from you� If you are enrolled in a Medicare Advantage
or a Medicare drug plan, the plan will contact you to investigate claims and request
repayment� You are responsible for cooperating with the Benefits Coordination &
Recovery Center, Medicare Advantage, or Medicare drug plan’s eorts to verify if
claims are related to your workers’ compensation settlement and repaying Medicare
for those claims from your Workers’, Compensation Medicare Set-aside Arrangement�
If you’re in another situation
What if I have Medicare and more than one other source of coverage?
Check with each of your types of coverage to find out who pays first� You can also
call the Benefits Coordination & Recovery Center at 1-855-798-2627� TTY users can
call 1-855-797-2627�
What happens if my health coverage changes?
Insurers must report health coverage changes to Medicare, but it can take some
time before they appear in Medicare’s records� If that happens, call the Benefits
Coordination & Recovery Center toll-free at 1-855-798-2627� TTY users can call
1-855-797-2627� When you call, you’ll need to tell them:
• Your name
• Your health plan’s name and address
• 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� Also, contact your health plan to make sure they reported the
changes to Medicare so your claims get paid correctly�
Section 2: How does Medicare work with other types of coverage? 21
Can I get coverage through the Health Insurance Marketplace® if I have
Medicare?
Generally, no� It’s against the law for someone who knows that you have Medicare
to sell or issue you a Marketplace policy� This is true even if you only have either
Medicare Part A or Medicare Part B� Therefore, if you already have Medicare, you
shouldn’t need to coordinate benefits between Medicare and a Marketplace plan�
On the other hand, if you don’t have Medicare yet, but have coverage through the
Marketplace, you can choose to keep your Marketplace plan after your Medicare
coverage starts� However, once your Medicare Part A coverage starts, any premium
tax credits or other savings you’ve been getting on a Marketplace plan will end� If you
choose to keep your Marketplace plan, you’ll have to pay full price for it�
If you age into Medicare and decide to keep your Marketplace plan, then Medicare
pays first� If you have questions about a Marketplace plan, call the Health Insurance
Marketplace® Call Center at 1-800-318-2596� TTY users can call 1-855-889-4325�
“Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health
& Human Services.”
Accessible Communications22
CMS Accessible Communications
Medicare provides free auxiliary aids and services, including information in
accessible formats like braille, large print, data/audio files, relay services and
TTY communications� If you request information in an accessible format, you
won’t be disadvantaged by any additional time necessary to provide it� This
means you’ll get extra time to take any action if there’s a delay in fulfilling your
request�
To request Medicare or Marketplace information in an accessible format you
can:
1. Call us:
For Medicare: 1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
For Marketplace: 1-800-318-2596
TTY: 1-855-889-4325
2. Email us: altformatreques[email protected]v
3. Send us a fax: 1-844-530-3676
4. Send us a letter:
Centers for Medicare & Medicaid Services
Oces of Hearings and Inquiries (OHI)
7500 Security Boulevard, Mail Stop DO-01-20
Baltimore, MD 21244-1850
Attn: Customer Accessibility Resource Sta (CARS)
Your request should include your name, phone number, type of information
you need (if known), and the mailing address where we should send the
materials� We may contact you for additional information�
Note: If you’re enrolled in a Medicare Advantage Plan or Medicare drug plan,
contact your plan to request its information in an accessible format� For
Medicaid, contact your state or local Medicaid oce�
Nondiscrimination Notice 23
Nondiscrimination Notice
The Centers for Medicare & Medicaid Services (CMS) doesn’t exclude, deny
benefits to, or otherwise discriminate against any person on the basis of race,
color, national origin, disability, sex (including sexual orientation and gender
identity), or age in admission to, participation in, or receipt of the services and
benefits under any of its programs and activities, whether carried out by CMS
directly or through a contractor or any other entity with which CMS arranges
to carry out its programs and activities�
You can contact CMS in any of the ways included in this notice if you have any
concerns about getting information in a format that you can use�
You may also file a complaint if you think you’ve been subjected to
discrimination in a CMS program or activity, including experiencing issues with
getting information in an accessible format from any Medicare Advantage Plan,
Medicare drug plan, state or local Medicaid oce, or Marketplace Qualified
Health Plans� There are 3 ways to file a complaint with the U�S� Department of
Health & Human Services, Oce for Civil Rights:
1. Online:
HHS.gov/civil-rights/filing-a-complaint/complaint-process/index.html
2. By phone:
Call 1-800-368-1019�
TTY users can call 1-800-537-7697�
3. In writing: Send information about your complaint to:
Oce for Civil Rights
U�S� Department of Health & Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D�C� 20201
24 Questions24
Questions
If you have questions about who pays first, or if your coverage changes, call the
Benefits Coordination & Recovery Center toll-free at 1-855-798-2627� TTY users can
call 1-855-797-2627�
The Benefits Coordination & Recovery Center helps to:
• Collect and manage information on other types of insurance or coverage that a
person with Medicare may have
• Determine if other coverage pays before or after Medicare
• Pursue repayment when Medicare makes a conditional payment, and another
payer is determined to be primary
When you call the Center, have your Medicare Number ready from your red, white,
and blue Medicare card� They may also ask for information like:
• Your Social Security Number (SSN)
• Your address
• Whether you have Medicare Part A (Hospital Insurance) and/or Medicare Part B
(Medical Insurance) and when your coverage started (in the lower right corner of
your Medicare card)
Need a copy of this booklet in Spanish?
To get a free copy of this booklet in Spanish, visit
Medicare�gov or call 1-800-MEDICARE
(1-800-633-4227)� TTY users can call 1-877-486-2048�
Esta publicación está disponible en Español� Para
obtener una copia gratis, visite Medicare�gov o llame al
1-800-MEDICARE�
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
7500 Security Blvd�
Baltimore, MD 21244-1850
Ocial Business
Penalty for Private Use, $300
CMS Product No� 02179 • 5/2024
The information in this booklet describes the Medicare Program at the time this booklet was printed�
Changes may occur after printing� Visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to get the
most current information� TTY users can call 1-877-486-2048�
“How Medicare Works With Other Insurance” isn’t a legal document� Ocial Medicare Program legal
guidance is contained in the relevant statutes, regulations, and rulings�
You have the right to get Medicare information in an accessible format, like large print, braille, or audio�
You also have the right to file a complaint if you feel you’ve been discriminated against� Visit
Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE
(1-800-633-4227) for more information� TTY users can call 1-877-486-2048�
This product was produced at U�S� taxpayer expense�
