★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★★

CENTERS FOR MEDICARE & MEDICAID SERVICES

Medicare and Other Health

Benefits: Your Guide to
Who Pays First

This official government

booklet tells you
★ How Medicare works with other
types of insurance or coverage
★ Who should pay your bills first
★ Where to get more help
 Welcome

Welcome to Medicare and Other Health Benefits:

Your Guide to Who Pays First
How This Guide Can Help You
This Guide explains how Medicare works with other kinds of insurance
or coverage and who should pay your bills first. Some people with
Medicare have other insurance or coverage that must pay before
Medicare pays its share of your bill. You may have more than one type
of insurance or coverage that will pay before Medicare. Tell your
doctor, hospital, and all other health providers about your other
insurance or coverage to make sure your bills are sent to the right payer
to avoid delays.

“ I used this Guide

when I needed
to know who
paid first for my
health care.”
 Table of Contents

Section 1: The Medicare Program . . . . . . . . . . . . . . . . . . . 1–4

What Is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Medicare Part A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Medicare Part B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Medicare Part C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Medicare Part D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Medicare Plan Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3–4

Section 2: Basic Information . . . . . . . . . . . . . . . . . . . . . . 5–10

Know Who Pays First . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5–7
General Information about Medicare and Other Insurance
or Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8–9

Section 3: Medicare and Other Types of Insurance or

Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11–32
Medicare and Group Health Plan Coverage . . . . . . . . . . . . . . . . . 12–14
Medicare and Group Health Plan Coverage After You Retire . . . 14–16
Medicare and Group Health Plan Coverage for People
Who Are Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16–17
Medicare and Group Health Plan Coverage for People with ESRD . . 18
Medicare and No-fault or Liability Insurance . . . . . . . . . . . . . . . 19–22
Medicare and Workers’ Compensation . . . . . . . . . . . . . . . . . . . . 22–26
Medicare and Veterans’ Benefits . . . . . . . . . . . . . . . . . . . . . . . . . 26–28
Medicare and TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28–29
Medicare and the Federal Black Lung Program . . . . . . . . . . . . . . 29–30
Medicare and COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30–32

Section 4: Words to Know . . . . . . . . . . . . . . . . . . . . . . . 33–34

Where words in red are defined

Section 5: Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35–36

An alphabetical list of what is in this Guide
“We keep this booklet
with other insurance
papers so we know
where to find it if we
have a question.”
 1
Section 1: The Medicare Program

What Is Medicare?
Medicare is health insurance for people age 65 or older, under age 65
with certain disabilities, and any age with End-Stage Renal Disease
(permanent kidney failure requiring dialysis or a kidney transplant).

Medicare has
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
• Medicare Part C (combines Part A and Part B coverage)
• Medicare Part D (prescription drug coverage)

Medicare Part A
Medicare Part A helps cover inpatient care in hospitals, including
critical access hospitals. It also covers skilled nursing facility, hospice,
and home health care. You must meet certain conditions to get these
benefits.
Cost: You usually don’t pay a monthly premium for Part A coverage
if you or your spouse paid Medicare taxes while working.
You pay up to $461 (in 2010) each month if you don’t get
Words in premium-free Part A. If you pay a late enrollment penalty, this
red are amount is higher.
defined
on pages
33–34.

1
 Section 1: The Medicare Program

Medicare Part B
Medicare Part B helps cover medical services like doctors’ services,
outpatient care, and other medical services Medicare Part A doesn’t
cover, if those services are medically necessary. Medicare Part B is
optional. You have to enroll in Part B and pay a monthly premium.
Your monthly premium depends on your income (see chart). Part B
also covers some preventive services.
Part B (Medical Insurance) Monthly Premium
If Your Yearly Income is (in 2008) You pay
File Individual Tax Return File Joint Tax Return
$85,000 or below $170,000 or below $110.50*
$85,001-$107,000 $170,001-$214,000 $154.70
$107,001-$160,000 $214,001-$320,000 $221.00
$160,001-$214,000 $320,001-$428,000 $287.30
Above $214,000 Above $428,000 $353.60
* Most people will continue to pay the 2009 Part B premium of $96.40 in
2010. If you have questions about your Part B premium, call Social
Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
You also pay a Medicare Part B deductible ($155 in 2010) each year
before Medicare starts to pay its share. Medicare premium and
deductible rates may change every year in January.

Medicare Part C
Medicare Advantage Plans (Part C) are another way to get your Medicare
benefits. They combine Part A, Part B, and, sometimes, Part D
(prescription drug) coverage. Medicare Advantage Plans are managed by
private insurance companies approved by Medicare. These plans must
Words in cover medically-necessary services. However, plans can charge different
red are copayments, coinsurance, or deductibles for these services.
defined
Medicare Part D
on pages
33–34. Medicare prescription drug coverage (Part D) is available to everyone
with Medicare. Private companies approved by Medicare provide this
coverage. If you are in Original Medicare, you choose a separate
Medicare Prescription Drug Plan and pay a monthly premium.
See page 4 for more information about Medicare Prescription Drug
2 Coverage. Costs vary by plan.
 Section 1: The Medicare Program

Below and on page 4 is a quick look at your Medicare plan choices.

People with Medicare can make changes to their coverage from
November 15—December 31 each year.
Original Medicare —This is a fee-for-service plan that is managed by
the Federal government. You can go to any doctor or supplier that is
enrolled in Medicare and accepts new Medicare patients. No referrals are
necessary.
Original Medicare covers most health care services and supplies, but
it doesn’t cover most prescription drugs. It only covers certain drugs
(like certain cancer drugs). If you don’t have prescription drug
coverage through another source (your employer, the VA, etc.) you
may want to enroll in a Medicare Prescription Drug Plan to help pay
for your prescription drugs. Also, you may want to buy additional
coverage, such as a Medigap (Medicare Supplement Insurance)
policy. You can choose one or both types of additional coverage.
Medicare Advantage Plans (like an HMO or PPO)—Medicare
Advantage Plans are health plan options approved by Medicare and run
by private companies. These plans are part of the Medicare Program and
are sometimes called “Part C” or “MA plans.” Medicare pays an amount
for your care every month to these private health plans. Medicare
Advantage Plans must follow rules set by Medicare. Medicare Advantage
Plans aren’t supplemental insurance.
Medicare Advantage Plans include the following:
• Medicare Preferred Provider Organization (PPO) Plans
• Medicare Health Maintenance Organization (HMO) Plans
• Medicare Private Fee-for-Service (PFFS) Plans
• Medicare Special Needs Plans
• Medicare Medical Savings Account (MSA) Plans
There are other Medicare health plans that provide health care
coverage that aren’t part of Medicare Advantage but are still part of
the Medicare Program. They include Medicare Cost Plans,
Demonstrations/Pilot Programs, and PACE (Programs of
All-inclusive Care for the Elderly).

3
 Section 1: The Medicare Program

Medicare Prescription Drug Coverage—Medicare offers

prescription drug coverage for everyone with Medicare. This is called
“Part D.” This coverage may help lower prescription drug costs and
help protect against higher costs in the future. It can give you greater
access to drugs that you can use to prevent complications from
diseases and stay well.
There are two ways to get Medicare prescription drug coverage:
1) Join a Medicare Prescription Drug Plan that adds drug coverage
to Original Medicare, some Medicare Cost Plans, some
Medicare Private Fee-for-Service Plans, and Medicare Medical
Savings Account Plans.
2) Join a Medicare Advantage Plan or other Medicare health plan
that includes prescription drug coverage as part of the plan. You
get all of your Medicare coverage through these plans, including
prescription drugs.
Generally, both types of these plans are called “Medicare drug plans.”
If you don’t join a Medicare drug plan when you are first eligible, the
next chance you have to join is from November 15—December 31
each year. If you decide later that you want to join a Medicare drug
plan, you may have to pay a penalty unless you had certain other
kinds of prescription drug coverage.
Important: If you have prescription drug coverage through an
employer or union, before you sign up for Medicare drug coverage
you need to check with your benefits administrator to learn how your
current coverage would be affected. In addition, if you have other
insurance that pays for your prescriptions and you join a Medicare
drug plan, you must let your Medicare drug plan know about your
other coverage.
For more information about Medicare drugs plans, get a free copy of
Words in “Your Guide to Medicare Prescription Drug Coverage” by visiting
red are www.medicare.gov/Publications/Pubs/pdf/11109.pdf or call
defined 1-800-MEDICARE (1-800-633-4227). TTY users should call
on pages 1-877-486-2048.
33–34.

4
 2
Section 2: Basic Information

Know Who Pays First If You Have Other Health Insurance or

Coverage
If you have Medicare and other health insurance or coverage, each type of coverage
is called a “payer.” When there is more than one payer, there are “coordination of
benefits” rules that decide which one pays first. The “primary payer” pays what it
owes on your bills first, and then sends the rest to the “secondary payer” to pay.
In some cases, there may also be a third payer.
Whether Medicare pays first depends on a number of things, including the
situations listed in the chart on the next two pages. However, this chart doesn’t cover
every situation.
Be sure to tell your doctor and other providers if you have coverage in addition to
Medicare. This will help them send your bills to the correct payer to avoid delays. If you
have questions about who pays first or if your insurance changes, call the Medicare
Coordination of Benefits Contractor (COBC) at 1-800-999-1118. TTY users should
call 1-800-318-8782.

5
 Section 2: Basic Information

If you Situation Pays first Pays second See

page(s)
Are 65 or older and covered Entitled to Medicare
by a group health plan
Group Medicare 12
because you or your spouse is The employer has 20
or more employees Health Plan
still working
The employer has less Medicare Group 13
than 20 employees.* Health Plan
Have an employer group
health plan after you retire Entitled to Medicare Medicare Retiree Coverage 14–16
and are 65 or older
Are disabled and covered Entitled to Medicare
by a large group health Large Group Health Plan
The employer has 100 Medicare 16–17
plan from your work, or or more employees.
from a family member who
is working The employer has less Medicare Group Health Plan 16
than 100 employees.
Have End-Stage Renal First 30 months of Medicare 18
Disease (permanent kidney eligibility or Group Health Plan
failure) and group health entitlement to
plan coverage (including a Medicare
retirement plan)
After 30 months Medicare Group Health Plan 18

Have End-Stage Renal First 30 months of COBRA Medicare 31

Disease (permanent kidney eligibility or
failure) and COBRA entitlement to
coverage Medicare
After 30 months Medicare COBRA 18
Are 65 or over OR disabled Entitled to Medicare Medicare COBRA 30– 31
and covered by Medicare
and COBRA coverage

* If your employer participates in a plan that is sponsored by two or more employers, the rules are slightly different.

6
 Section 2: Basic Information

If you Situation Pays first Pays second See

page(s)
Have been in an accident Entitled to Medicare No-fault or Liability Medicare 19–22
where no-fault or liability insurance for services related
insurance is involved to accident claim
Are covered under workers’ Entitled to Medicare Workers’ compensation for Usually doesn’t 22– 26
compensation because of a services related to workers’ apply. However,
job-related illness or injury compensation claim Medicare may make
a conditional
payment.
Are a Veteran and have Entitled to Medicare Medicare pays for Medicare- Usually doesn’t 26– 28
Veterans’ benefits and Veterans’ benefits covered services. apply
Veterans’ Affairs pays for
VA-authorized services.
Note: Generally, Medicare
and VA can’t pay for the
same service.

Are covered under Entitled to Medicare Medicare pays for Medicare- TRICARE may pay 28– 29
TRICARE and TRICARE covered services. second.
TRICARE pays for services
from a military hospital or
any other federal provider.

Have black lung disease and Entitled to Medicare Federal Black Lung Medicare 29– 30
covered under the Federal and Federal Black Program for services related
Black Lung Program Lung Program to black lung

7
 Section 2: Basic Information

General Information about Medicare and Other

Insurance or Coverage
I’m not yet 65. How will Medicare know I have other insurance
or coverage?
Medicare doesn’t automatically know if you have other insurance or
coverage. Medicare sends you a questionnaire called the “Initial
Enrollment Questionnaire” about 3 months before you’re entitled to
Medicare. This questionnaire will ask you if you have group health
plan coverage through your work or that of a family member. Your
answers to this questionnaire are used to help Medicare set up your
file and make sure your claims are paid correctly.

Example
Harry is almost 65 and is getting ready to retire and enroll in
Medicare. Harry’s wife, Jane, is 63, and works for a large
company (more than 20 people). Both Harry and Jane have
health insurance coverage through Jane’s employer’s group
health plan. When Harry gets the Initial Enrollment
Questionnaire in the mail from Medicare, he fills it out and
reports that he has insurance through his wife’s employment.
This insurance will pay Harry’s claims first, and Medicare will
pay claims second.

What happens if my health insurance or coverage changes

after I fill out the Initial Enrollment Questionnaire?
If your health insurance or coverage changes, you will need to call the
Medicare Coordination of Benefits Contractor at 1-800-999-1118. TTY
users should call 1-800-318-8782. Give the Medicare Coordination of
Words in Benefits Contractor your name; the name and address of your health
red are plan; your policy number; and the date coverage was added, changed or
defined stopped, and why. Tell your doctor and other providers about the
change in your insurance or coverage when you get care.
on pages
33–34.

8
 Section 2: Basic Information

General Information about Medicare and Other Insurance or

Coverage (continued)
What if I have Medicare and more than one type of insurance or
coverage?
If you have a question about who should pay, or who should pay first,
check your insurance policy or coverage. It may include the rules about
who pays first. You can also call the Medicare Coordination of Benefits
Contractor at 1-800-999-1118. TTY users should call 1-800-318-8782.
When is Medicare a secondary payer for domestic partners with
group health insurance coverage?
Medicare is generally a secondary payer for domestic partners:
• When the domestic partner is entitled to Medicare on the basis of
disability and covered by a large group health plan on the basis of
his/her own current employment status or that of a family member
(A domestic partner is considered a family member);
• For a 30-month coordination period when the domestic partner is
eligible for Medicare on the basis of end stage renal disease (ESRD)
and is covered by a group health plan on any basis;
• When the domestic partner is entitled to Medicare on the basis of
age and has group health plan coverage on the basis of his/her own
current employment status.
When is Medicare a primary payer for domestic partners with
group health insurance coverage?
If a domestic partner is entitled to Medicare on the basis of age and has
group health plan coverage based on the current employment status of
his/her partner.

Who should I call if I have a general question about who pays first?
Words in You should call the benefits administrator at your health insurance plan.
You can also call the Medicare Coordination of Benefits Contractor at
red are 1-800-999-1118. TTY users should call 1-800-318-8782.
defined
on pages
33–34.

9
 Section 2: Basic Information

Notes

10
 3
Section 3: Medicare and Other Types of Insurance or Coverage

This section has more detailed information about the different

types of coverage you might have, and how they work with
Medicare.

Section 3 includes
Medicare and Group Health Plan Coverage . . 12–14

Medicare and Group Health Plan Coverage

After You Retire . . . . . . . . . . . . . . . . . . . . 14–16

Medicare and Group Health Plan Coverage for

People Who are Disabled . . . . . . . . . . . . . 16–17

Medicare and Group Health Plan Coverage for

People with ESRD . . . . . . . . . . . . . . . . . . . . . 18

Medicare and No-fault or Liability Insurance . 19–22

Medicare and Workers’ Compensation . . . . . 22–26

Medicare and Veterans’ Benefits . . . . . . . . . . . 26–28

Medicare and TRICARE . . . . . . . . . . . . . . . . 28–29

Medicare and the Federal Black Lung Program . 29–30

Medicare and COBRA . . . . . . . . . . . . . . . . . . 30–32

11
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Group Health Plan Coverage

When you turn 65, you have a number of important decisions to make.
These may include whether to enroll in Medicare Part B, join a Medicare
Prescription Drug Plan, buy a Medigap policy, and/or keep employer or
retiree coverage. Understanding your choices may help you avoid paying more
than you need to for Medicare Part B and other insurance, and get the
coverage that’s best for you. You can visit www.medicare.gov and select
“Compare Medicare Prescription Drug Plans” and “Compare Health Plans
and Medigap Policies in Your Area.” You can also call your State Health
Insurance Assistance Program. To get their telephone number, call
1-800-MEDICARE (1-800-633-4227). TTY users should call
1-877-486-2048.
What is group health plan coverage?
Group health plan coverage is coverage offered by many employers and
unions for current employees or retirees. You may also get group health
plan coverage through the employer of a spouse or family member.
If you have Medicare and you are offered coverage under a group health
plan, you can choose to accept or reject the plan. Note that the group
health plan may be a fee-for-service plan or a managed care plan, like an
HMO or PPO.
I have Medicare and group health plan coverage. Who pays first?
Generally, your group health plan pays first if the following conditions apply:
• You’re age 65 or older and covered by a group health plan because of your
Words in current employment or the current employment of a spouse of any age.
red are • The employer has 20 or more employees and covers any of the same
services as Medicare. This means that the group health plan pays first on
defined
your hospital and medical bills. If the group health plan didn’t pay all of
on pages your bill, the doctor or provider should send the bill to Medicare for
33–34. secondary payment. Medicare will review what your group health plan
paid, and pay any additional costs up to the Medicare-approved
amounts. You will have to pay the costs of services that Medicare or the
group health plan doesn’t cover.

12
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Group Health Plan Coverage (continued)

I have Medicare, and I work for a small company that has a group
health plan. Who pays first?
If your employer has fewer than 20 employees, Medicare generally pays first.
But if your employer joins with other employers or employee organizations
(like unions) to sponsor a group health plan (called a multi-employer plan),
and any of the other employers have 20 or more employees, Medicare would
generally pay second. However, your plan might ask for an exception. So
even if your employer has fewer than 20 employees, you will need to find
out from your employer whether Medicare pays first or second.
If my group health plan is a Health Maintenance Organization
(HMO) Plan or an employer Preferred Provider Organization (PPO)
Plan that is primary to Medicare, who pays if I go outside the
employer plan’s network?
If you go outside your employer plan’s network, you might not get any
payment from the plan or Medicare. Call your employer plan before you
go outside the network to find out if the service will be covered.
I decided not to take group health plan coverage from my employer.
Will this affect what Medicare will pay?
If you don’t take group health plan coverage from your employer and you
don’t have coverage through an employed spouse, Medicare payment isn’t
affected. Medicare will pay its share for any Medicare-covered health care
service you get.
What happens if I drop coverage from my employer?
Medicare pays first unless you have coverage through an employed spouse,
and your spouse’s employer has at least 20 employees.
Note: If you don’t take or you drop employer coverage when it is first
offered to you, you might not get another chance to sign up. If you take
the coverage, but later drop it, you may not be able to get it back. Also, if
your or your spouse’s employer generally offers retiree coverage (see
page 14), you might be denied that coverage if you weren’t enrolled in the
plan while you or your spouse was still working. Call your employer’s
benefits administrator for more information before you make a decision.

13
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Group Health Plan Coverage (continued)

What health benefits must my employer provide if I am age 65 or older
and still working?
Generally, employers with 20 or more employees must offer the same health
benefits, under the same conditions, to current employees age 65 and older as
they offer to younger employees. If the employer offers coverage to spouses,
they must offer the same coverage to spouses age 65 and older that they offer
to spouses under age 65.

Medicare and Group Health Plan Coverage After

You Retire
How does my group health plan coverage work after I retire?
This will depend on the terms of your specific plan. Your or your spouse’s
employer or union might not provide any health coverage after you retire. If
group health plan coverage continues to be available after you retire, it might
have different rules, and it might not work the same way with Medicare.
First, find out if you can continue your employer coverage after you retire.
Note that employers aren’t required to provide retiree coverage, and they can
change the benefits or premiums, or even cancel the coverage.
Second, find out what happens to your retiree coverage when you’re eligible
for Medicare. For example, retiree coverage might not pay your medical costs
during any period in which you were eligible for Medicare but didn’t sign up
for it. When you become eligible for Medicare, you may need to enroll in
both Medicare Part A and Medicare Part B to get full benefits from your
Words in retiree coverage.
red are
defined
on pages
33–34.

14
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Group Health Plan Coverage After You Retire

(continued)
How does my group health plan coverage work after I retire?
Since Medicare pays first after you retire, your retiree coverage is likely to be
similar to coverage under a Medigap (Medicare Supplement Insurance)
policy. Retiree coverage isn’t the same thing as a Medigap policy. However,
like a Medigap policy, it usually offers benefits that fill in some of Medicare’s
gaps in coverage, such as coinsurance and deductibles, and it sometimes
includes extra benefits, like coverage for extra days in the hospital.
Check the price and benefits of the retiree coverage, including whether it
includes coverage for your spouse. Retiree coverage provided by your
employer or union may have limits on how much it will pay. It might only
provide “stop loss” coverage, which starts paying your out-of-pocket costs
only when they reach a maximum amount.
It would make sense to compare the retiree coverage to available Medigap
policies. The best time to buy a Medigap policy is during your 6-month open
enrollment period, when you can buy any Medigap policy sold in your state,
even if you have health problems. This period automatically starts the month
you’re age 65 and enrolled in Part B, and once it’s over, you can’t get it again.
Also, remember that you and your spouse would each have to have your own
Medigap policy, and you can only buy a policy when you’re eligible for
Medicare. For more information about Medigap policies, visit
www.medicare.gov/Publications/Pubs/pdf/02110.pdf to view the booklet
“Choosing a Medigap Policy: A Guide to Health Insurance for People with
Medicare.” To find and compare Medigap plocies, visit www.medicare.gov and
Words in select “Compare Medicare Health Plans and Medigap Policies in Your Area.”
red are Or, call 1-800-MEDICARE (1-800-633-4227). TTY users should call
defined 1-877-486-2048.
on pages Make sure you know what effect your continued coverage as a retiree will
33–34. have on both your and your spouse’s health coverage. If you aren’t sure how
your retiree coverage works with Medicare, get a copy of your plan’s benefit
booklet, or look at the summary plan description provided by your employer
or union. You can also call your employer’s benefits administrator and ask
how the plan pays when you have Medicare. It would also be a good idea to
talk to your State Health Insurance Assistance Program (SHIP) for advice
about whether to buy a Medigap policy.

15
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Group Health Plan Coverage After You Retire

(continued)
Note: Generally, when you have retiree coverage from an employer
or union, they control this coverage. They may change the benefits
or the premiums and can also cancel the coverage if they choose.
I’m retired and have Medicare. I also have group health plan
coverage from my former employer. Who pays first?
Generally, Medicare will pay first for your health care bills and your
group health plan (retiree) coverage will pay second.
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, you may
be protected under Federal COBRA rules if there is any other
company within the same corporate organization that still offers a
group health plan to its employees. If there is, that plan is required
to offer you COBRA continuation coverage through that plan. See
pages 30–32. If COBRA continuation coverage isn’t available, you
may have the right to buy a Medigap policy, even if you’re no longer
in your Medigap open enrollment period.

Medicare and Group Health Plan Coverage for

People Who Are Disabled (Non-ESRD Disability)
I’m under age 65, disabled, and have Medicare and group health
plan coverage based on current employment. Who pays first?
Words in It depends. Generally, if your employer has less than 100 employees,
red are Medicare pays first if the following are true:
defined • You are under age 65.
on pages • You have Medicare because of a disability.
33–34.
If the employer has 100 employees or more, the health plan is called
a large group health plan. If you are covered by a large group health
plan because of your current employment or the current
employment of a family member, Medicare pays second.

16
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Group Health Plan Coverage for People Who

Are Disabled (Non-ESRD Disability) (continued)
I’m under age 65, disabled, and have Medicare and group health
plan coverage based on current employment. Who pays first?
Sometimes employers with fewer than 100 employees join other
employers to form a multi-employer plan. If at least one employer in
the multi-employer plan has 100 employees or more, then Medicare
pays second. Some large group health plans let others join the plan,
such as a self-employed person, a business associate of an employer,
or a family member of one of these people. A large group health plan
can’t treat any of its plan members differently because they’re
disabled and have Medicare.

Example
Mary works full-time for XYZ Company, which has 120
employees. She has large group health plan coverage for herself
and her husband. Her husband has Medicare because of a
disability. Therefore, Mary’s group health plan coverage pays
first for Mary’s husband, and Medicare pays second.

Words in
red are
defined
on pages
33–34.

17
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Group Health Plan Coverage for

People with End-Stage Renal Disease (ESRD)
(permanent kidney failure)
I have ESRD and group health plan coverage. Who pays first?
If you’re eligible for Medicare because of ESRD, your group health
plan will pay first on your hospital and medical bills for 30 months,
whether or not you’re enrolled in Medicare and have a Medicare card.
During this time, Medicare pays second. The group health plan pays
first during this period no matter how many employees work for your
employer, or whether you or a family member are currently employed.
At the end of the 30 months, Medicare pays first. This rule applies to
most people with ESRD, whether you have your own group health
plan coverage, or you’re covered as a family member.

Example
Bill has Medicare coverage because of ESRD (permanent kidney
failure). He also has group health plan coverage through his
company. Bill’s group health plan coverage will pay first for the
first 30 months after he becomes eligible for Medicare. After 30
months, Medicare pays first.

Words in
red are
defined
on pages
33–34.

18
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and No-fault or Liability Insurance

What is no-fault insurance?
No-fault insurance is insurance that pays for health care services resulting
from injury to you or damage to your property in an accident, regardless
of who is at fault for causing the accident.
Some types of no-fault insurance include, but aren’t limited to, the following:
• Automobile insurance
• Homeowners’ insurance
• Commercial insurance plans
What is liability insurance?
Liability insurance is coverage that protects the policyholder against
claims for negligence, inappropriate action, or inaction that results in
injury to someone or damage to property.
Liability insurance includes, but isn’t limited to, the following:
• Homeowners’ liability insurance
• Automobile liability insurance
• Product liability insurance
Words in • Malpractice liability insurance
red are • Uninsured motorist liability insurance
defined • Underinsured motorist liability insurance
on pages If you have an insurance claim for your medical expenses, you or your
33–34. attorney should notify Medicare as soon as possible.

19
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and No-fault or Liability Insurance (continued)

Who pays first if I have a claim for no-fault or liability insurance?
No-fault insurance or liability insurance pays first and Medicare pays
second, if appropriate.

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 hospital
emergency room, Nancy is asked about available insurance
coverage related to the accident. Nancy tells the hospital that her
granddaughter has Med Pay coverage. Because this insurance pays
regardless of fault, it is considered no-fault insurance. The hospital
bills the no-fault insurance for the emergency room services, and
only bills Medicare if any Medicare-covered services aren’t paid
for by the liability insurance.

If I expect to get money from no-fault or liability insurance,

and I also have Medicare, which one should pay first?
As explained on page 19, no-fault or liability insurance should pay first.
Note: Paying “first” means paying the whole bill up to the limits of the
coverage. It doesn’t always mean that the primary payer pays first in
Words in time. If doctors or other providers are told that you have a no-fault or
red are liability insurance claim, they must try to get payments from the
insurance company before billing Medicare. However, this may take a
defined long time. If the insurance company doesn’t pay the claim promptly
on pages (usually within 120 days), your doctor or other provider may bill
33–34. Medicare. Medicare may make a conditional payment to pay the bill, and
then later recover any payments that the primary payer should have made.

20
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and No-fault or Liability Insurance (continued)

What is a conditional payment?
A conditional payment is a payment that Medicare makes for services
for which another payer is potentially responsible. This conditional
payment is made 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 when a settlement, judgment, or award is reached.
Note: If Medicare makes a conditional payment, and you get a
settlement from an insurance company later, Medicare will recover the
conditional payment from your settlement. You are responsible for
making sure that Medicare gets repaid for the conditional payment.

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
liability insurer. 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
health care services that Joan received. Later, when a settlement is
reached with the liability insurer, Joan must make sure that
Medicare gets its money back for the conditional payment.

Words in
red are
defined
on pages
33–34.

21
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and No-fault or Liability Insurance (continued)

How does Medicare get its money back for the conditional
payment?
If Medicare makes a conditional payment, you or your representative should
call the Medicare Coordination of Benefits Contractor (COBC) at
1-800-999-1118. TTY users should call 1-800-318-8782. The COBC will
notify the recovery contractor to work on your case. The recovery contractor
is a separate contractor responsible for getting conditional payments repaid to
Medicare.
The recovery contractor will use the information you or your representative
gave to the COBC. It will gather information about any conditional
payments Medicare made which relate to your pending settlement,
judgment, or award. Once a settlement, judgment, or award is final, you or
your representative should call the recovery contractor. The recovery
contractor will get the final repayment amount (if any) on your case and
issue a letter requesting repayment.
Who pays if the no-fault or liability insurance denies my medical
bill or is found not liable for payment?
In this case, Medicare will pay the same as it would if it were the only
payer. However, Medicare will only pay for Medicare-covered services, and
you will be responsible for your share of the bill (for example, coinsurance,
copayment, or deductible) and for services that Medicare doesn’t cover.
Who should I call if I have questions?
If you have questions about a no-fault or liability insurance claim,
call the insurance company. If you have questions about who pays first,
call the Medicare Coordination of Benefits Contractor at
1-800-999-1118. TTY users should call 1-800-318-8782.
Medicare and Workers’ Compensation
What is workers’ compensation?
Words in
red are Workers’ compensation is a law or plan of the United States or any
state, that requires employers to cover employees who get sick or
defined injured on the job. Most employees are covered under workers’
on pages compensation plans. If you don’t know whether you’re covered, ask
33–34. your employer, or contact your state workers' compensation division or
department.

22
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Workers’ Compensation (continued)

I have Medicare and filed a workers’ compensation claim.
Who pays first?
If you have Medicare and get injured on the job, workers’ compensation pays
first on the bills for health care items or services you got because of your
work-related illness or injury. There can be a delay between when a bill is
filed for the work-related illness or injury and when the state workers’
compensation insurance decides if they should pay the bill. Medicare can’t
pay for items or services that workers’ compensation will pay for promptly
(usually 120 days). However, if the workers’ compensation insurer denies
payment for your medical bills pending a review of your claim, Medicare may
Words in make a conditional payment.
red are If you think you have a work-related illness or injury, tell your
defined employer, and file a workers’ compensation claim.
on pages You or your lawyer also need to call the Medicare Coordination of Benefits
33–34. Contractor (COBC) at 1-800-999-1118 as soon as you file your workers’
compensation claim. TTY users should call 1-800-318-8782.

Example
Tom was injured at work. He filed a claim for workers’ compensation
insurance. His doctor billed the state workers’ compensation insurance
for payment. Payment wasn’t received in 120 days. Tom’s doctor
billed Medicare and sent a copy of the workers’ compensation claim
with the claim for Medicare payment. Medicare can make a
conditional payment to the doctor for the health care services that
Tom received. When a settlement is reached with the state workers’
compensation agency, Tom must make sure that Medicare gets its
money back for the conditional payment.

How does Medicare get its money back for the conditional payment?
If Medicare makes a conditional payment, and you or your lawyer haven’t
reported your worker’s compensation claim to Medicare, you should call
the Medicare Coordination of Benefits Contractor (COBC) at
1-800-999-1118. TTY users should call 1-800-318-8782.

23
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Workers’ Compensation (continued)

How does Medicare get its money back for the conditional payment?
(continued)
If your lawyer contacts Medicare for you, your lawyer should call the
Coordination of Benefits Contractor (COBC) at 1-800-999-1118.
TTY users should call 1-800-318-8782. The COBC will notify the recovery
contractor to work on your case. The recovery contractor will use the
information that you or your lawyer gave to the COBC. It will gather
information about any conditional payments Medicare made that relate to
your pending settlement, judgment, or award. Once a settlement, judgment,
or award is final, you or your lawyer should call the recovery contractor.
The recovery contractor will identify the final repayment amount (if any) on
your case and issue a letter requesting repayment.
What if I want to settle my workers’ compensation claim?
Settlements of workers’ compensation claims are handled differently than a
settlement of a no-fault or liability insurance claim. As part of settling your
workers’ compensation claim, you must repay Medicare for any Medicare
payments for workers’ compensation claim-related services that you have
already received. However, the settlement may also provide for funds to be
set aside to pay for future medical and/or prescription drug services related
to the workers’ compensation injury or illness/disease.
When you have Medicare, these funds should be deposited into a Workers’
Compensation Medicare Set-aside Arrangement (WCMSA), which may be
set up by your workers’ compensation lawyer. The purpose of the WCMSA
is to make sure the workers’ compensation funds are spent on expenses that
Words in would otherwise by covered by Medicare. In other words, workers'
red are compensation pays before Medicare, even after a settlement.
defined If you want to settle your workers’ compensation claim, you or your lawyer
on pages should contact the recovery contractor. If your proposed settlement includes
33–34. funds for any future medical services and/or prescription drug expenses, you
or your lawyer should send your proposed WCMSA to the Medicare
Coordination of Benefits Contractor at the address below:
CMS
c/o Coordination of Benefits Contractor
P.O. Box 33849
Detroit, MI 48232
Attention: WCMSA Proposal

24
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Workers’ Compensation (continued)

I have a Workers’ Compensation Medicare Set-aside Arrangement
(WCMSA). How do I use the money if I manage (self-administer) my
Medicare set-aside arrangement?
If you have a WCMSA as part of your workers’ compensation settlement,
you must be careful how you spend the money that was specifically set
aside for Medicare. The money that was placed in your WCMSA is to
pay for future medical and/or prescription drug expenses related to your
work injury or illness/disease that would otherwise have been covered
(payable) by Medicare. This means you can’t use the WCMSA to pay for
any other work injury, or any medical items or services that Medicare
doesn’t cover (for example, dental services).
In addition, Medicare won’t pay for any medical expenses related to the injury
until after you have used all of your set-aside money appropriately. If you
aren’t sure what type of services Medicare covers, you should call Medicare for
more information before you use any of the money that was placed in your
WCMSA. For more information, call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users should call 1-877-486-2048.
Be sure to keep records of your workers’ compensation-related medical
and/or prescription drug expenses. These records show what items and
services you got and how much money you spent on your work injury or
illness/disease. You will need these records to prove that you used your
WCMSA money to pay your workers’ compensation-related medical
and/or prescription drug expenses. After you use all of your WCMSA
Words in money appropriately, Medicare can start paying for Medicare-covered
red are services related to your work injury or illness/disease.
defined Note: Workers’ compensation claims can be resolved by settlements,
on pages judgments, or awards. The information listed here about WCMSAs only
33–34. applies to settlements.

25
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Workers’ Compensation (continued)

What if workers’ compensation denies payment?
If the state workers’ compensation insurance denies payment, and if
you provide proof to Medicare that the claim was denied, then
Medicare will pay for Medicare-covered items and services.

Mike was injured at work. He filed a claim for workers’ compensation.

The workers’ compensation agency denied payment for Mike’s medical
bills. Mike’s doctor billed Medicare and sent a copy of the workers’
compensation denial with the claim for Medicare payment. Medicare
will pay Mike’s doctor for the Medicare-covered items and services
Mike got as part of his treatment. Mike will have to pay for anything
Medicare doesn’t cover.

Can workers’ compensation decide not to pay my entire bill?

In some cases, workers’ compensation insurance may not pay your
entire bill. 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.
You and workers’ compensation insurance may agree to share the cost
of your bill. 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.
Words in
red are Medicare and Veterans’ Benefits
defined I have Medicare and Veterans’ benefits. Who pays first?
on pages If you have or can get both Medicare and Veterans’ benefits, you can get
33–34. treatment under either program. When you get health care, you must
choose which benefits to use each time you see a doctor or get health care.
Medicare can’t pay for the same service that was covered by Veterans’
benefits, and your Veterans’ benefits can’t pay for the same service that
was covered by Medicare. You don’t always have to go to a Department of
Veterans Affairs (VA) hospital or to a doctor who works with the VA for
the VA to pay for the service. To get the VA to pay for services you must
go to a VA facility or have the VA authorize services in a non-VA facility.

26
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Veterans’ Benefits (continued)

Are there any situations when both Medicare and the VA can pay?
Yes. If the VA authorizes services in a non-VA hospital, but doesn’t
pay for all of the services you get during your hospital stay, then
Medicare may pay for the Medicare-covered part of the services that
the VA doesn’t pay for.

Bob, a veteran, goes to a non-VA hospital for a service that is

authorized by the VA. While at the non-VA hospital, Bob gets other
non-VA authorized services that the VA refuses to pay for. Some of
these services are Medicare-covered services. Medicare may pay for
some of the non-VA authorized services that Bob got. Bob will have
to pay for services not covered by Medicare or the VA.

Can Medicare help pay my VA copayment?

Sometimes. The VA charges a copayment to some veterans. The
copayment is your share of the cost of your treatment and is based
on income. Medicare may be able to pay all or part of your
copayment if you are billed for VA-authorized care by a doctor or
hospital who isn’t part of the VA.
I have a VA fee-basis identification (ID) card. Who pays first?
The VA gives “fee-basis ID cards” to certain veterans. You may be
given a fee-basis ID card if the following conditions apply:
• You have a service-connected disability.
Words in • You will need medical services for an extended period of time.
red are • There are no VA hospitals in your area.
defined If you have a fee-basis ID card, you may choose any doctor who is
on pages listed on your card to treat you.
33–34. If the doctor accepts you as a patient and bills the VA for services,
the doctor must accept the VA’s payment as payment in full. The
doctor can’t bill either you or Medicare for these services.
If your doctor doesn’t accept the fee-basis ID card, you will need to
file a claim with the VA yourself. The VA will pay the approved
amount to either you or your doctor.

27
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and Veterans’ Benefits (continued)

Who should I call if I need more information?
You can get more information on Veterans’ benefits by calling your
local VA office or the national VA information number at
1-800-827-1000. TTY users should call 1-800-829-4833. You can
also visit www.va.gov.

Medicare and TRICARE

What is TRICARE?
TRICARE is a health care program for active-duty and retired
uniformed services members and their families. TRICARE includes
the following:
• TRICARE Prime
• TRICARE Extra
• TRICARE Standard
• TRICARE for Life (TFL)
What is TRICARE for Life?
TRICARE for Life (TFL) was created to provide expanded medical
coverage to Medicare-eligible uniformed services retirees age 65 or
older, their eligible family members and survivors, and certain
former spouses. To get TFL benefits, you must have Medicare
Part A and Part B.
Can I have both Medicare and TRICARE?
Words in The following groups of people can have both Medicare and other
red are types of TRICARE:
• Dependents of active-duty service members who are entitled to
defined
Medicare for any reason
on pages • People under age 65 who are entitled to Medicare Part A
33–34. because of a disability or End-Stage Renal Disease (ESRD) and
enrolled in Medicare Part B
• People age 65 or older who are entitled to Medicare Part A and
enrolled in Medicare Part B

28
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and TRICARE (continued)

I have Medicare and TRICARE. Who pays first?
In general, Medicare pays first for Medicare-covered services. TRICARE
will pay the Medicare deductible and coinsurance amounts and for any
service not covered by Medicare that TRICARE covers. You will have to
pay the costs of services that Medicare or TRICARE doesn’t cover.
Who pays if I get services from a military hospital?
If you get services from a military hospital or any other federal provider,
TRICARE will pay the bills. Medicare usually doesn’t pay for services
you get from a federal provider or other federal agency.
Who should I call if I need more information?
You can get more information on TRICARE by calling the health
benefits advisor at a military hospital or clinic. You can also call
1-866-773-0404, or visit www.TRICARE.osd.mil.

Medicare and the Federal Black Lung Program

I have Medicare and coverage under the Federal Black Lung
Program. Who pays first?
The Federal Black Lung Program pays first for any health care for black
lung disease covered under that program. Medicare won’t pay for doctor
or hospital services covered under the Federal Black Lung Program. Your
doctor or other provider should send all bills for the diagnosis or
treatment of black lung disease to the following address:

Words in Federal Black Lung Program

red are P.O. Box 8302
London, KY 40742-8302
defined
on pages For all other health care not related to black lung disease, Medicare pays
33–34. first, and you should send your bills directly to Medicare.
What if the Federal Black Lung Program won’t pay my bill?
If the Federal Black Lung Program won’t pay your bill, your doctor or
other provider can send the bill to Medicare. Your doctor or other
provider should send your bill and a copy of the letter from the Federal
Black Lung Program that says why it won’t pay your bill.

29
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and the Federal Black Lung Program (continued)

Who should I call if I have questions?
If you have questions about the Federal Black Lung Program, call
1-800-638-7072. If you have questions about who pays first, call
the Medicare Coordination of Benefits Contractor at
1-800-999-1118. TTY users should call 1-800-318-8782.

Medicare and COBRA (The Consolidated Omnibus

Budget Reconciliation Act of 1985)
What is COBRA?
COBRA is a federal law that may let you keep your employer
group health plan coverage for a limited time after your
employment ends or after you would otherwise lose coverage.
This is called “continuation coverage.”
In general, COBRA only applies to employers with 20 or more
employees. However, some state laws require insurers covering
employers with fewer than 20 employees to let you keep your
coverage for a period of time. In most situations that give you
COBRA rights, other than a divorce, you should get a notice from
your employer’s benefits administrator or the group health plan
telling you that your coverage is ending and offering you the right
to elect COBRA continuation coverage, generally for 18 months, or
in some cases 36 months. If you don’t get a notice, but you find
out that your coverage has ended, or if you get divorced, you
should call the employer’s benefits administrator or the group
health plan as soon as possible and ask about your COBRA rights.

Words in
red are
defined
on pages
33–34.

30
Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and COBRA (continued)

I have Medicare and COBRA continuation coverage. Who pays first?
In general, the rules described on pages 12–16 that apply to group health plan
coverage apply to COBRA continuation coverage as well. For example, if you
or your spouse are retired and have COBRA continuation coverage, Medicare
pays first.
However, if you have Medicare based on End-Stage Renal Disease (ESRD),
COBRA continuation coverage pays first, and Medicare pays second to the
extent COBRA coverage overlaps the first 30 months of Medicare eligibility or
entitlement based on ESRD.
This publication can only give a brief description of COBRA coverage and
who pays first. The decision about whether and when to elect COBRA can be
very complicated. When you lose employer coverage and you have Medicare,
you need to be aware of your COBRA election period, your Part B enrollment
period, and your Medigap open enrollment period. These may all have
different deadlines that overlap, and what you decide about one type of
coverage (COBRA, Part B, and Medigap) might cause you to lose rights under
one of the other types of coverage.

Words in
red are
defined
on pages
33–34.

31
 Section 3: Medicare and Other Types of Insurance or Coverage

Medicare and COBRA (continued)

Who should I call if I have questions about COBRA?
• Before you elect COBRA coverage, it’s a good idea to talk with your State
Health Insurance Assistance Program (SHIP) about Part B and Medigap.
To get their telephone number, call 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048.
• You can also get a free copy of “Choosing a Medigap Policy: A Guide to
Health Insurance for People with Medicare.” You can visit
www.medicare.gov/Publications/Pubs/pdf/02110.pdf or call
1-800-MEDICARE.
• Call your employer’s benefits administrator for questions about your
specific COBRA options.
• If you have questions about Medicare and COBRA, call the Medicare
Coordination of Benefits Contractor at 1-800-999-1118. TTY users should
call 1-800-318-8782.
• If your group health plan coverage was from a private employer (not a
government employer), you can visit the Department of Labor’s (DoL)
Web site at www.dol.gov, or call 1-866-444-3272.
• If your group health plan coverage was from a state or local government
employer, you can call 1-877-267-2323 extension 61565.
• If your coverage was with the Federal government, you can visit the Office
of Personnel Management’s website at www.opm.gov.

32
 4
Section 4: Words to Know

Claim—A claim is a request for payment

that you submit to Medicare or other
health insurance when you receive items
Medicare Coordination of Benefits
Contractor— The company that acts
on behalf of Medicare to collect and
and services that you think are covered. manage information on other types of
insurance or coverage that a person
Coinsurance—An amount you may be with Medicare may have, and
required to pay as your share of the cost for determine whether the coverage pays
services, after you pay any deductibles. before or after Medicare.
Coinsurance is usually a percentage (for
example, 20%). Medicare Part A (Hospital Insurance)—
Hospital insurance that pays for inpatient
Copayment—An amount you may be hospital stays, care in a skilled nursing
required to pay as your share of the cost for facility, hospice care, and some home
a medical service or supply, like a doctor’s health care.
visit or a prescription. A copayment is
Medicare Part B (Medical Insurance)—
usually a set amount, rather than a
Coverage for certain doctors’ services,
percentage. For example, you might pay
outpatient care, medical supplies, and
$10 or $20 for a doctor’s visit or
preventive services.
prescription.
Medicare Prescription Drug Plan (Part
Deductible—The amount you must pay D)—A stand-alone drug plan that adds
for health care or prescriptions, before prescription drug coverage to Original
Original Medicare, your prescription drug Medicare, some Medicare Cost Plans,
plan, or your other insurance begins to pay. some Medicare Private-Fee-for-Service
Plans, and Medicare Medical Savings
End-Stage Renal Disease—Permanent Account Plans. These plans are offered
kidney failure that requires a regular course by insurance companies and other
of dialysis or a kidney transplant. private companies approved by
Medicare. Medicare Advantage Plans
Group Health Plan—In general, a health may also offer prescription drug coverage
plan offered by an employer or employee that follows the same rules as Medicare
organization that provides health coverage Prescription Drug Plans.
to employees, former employees, and their
families. Medigap Policy—Medicare
Supplement Insurance sold by private
Large Group Health Plan—In general, a insurance companies to fill “gaps” in
group health plan that covers employees of Original Medicare coverage.
either an employer or employee Multi-Employer Plan—In general, a
organization that has 100 or more group health plan that is sponsored
employees. jointly by two or more employers.

33
 Section 4: Words to Know

Original Medicare—Original Medicare is

fee-for-service coverage under which the
government pays your health care
providers directly for your Part A and/or
Part B benefits.
Premium—The periodic payment to
Medicare, an insurance company, or a
health care plan for health or prescription
drug coverage.
Provider —A doctor, hospital, health care
professional, or health care facility.
Recovery Contractor—A company that
acts on behalf of Medicare to obtain
repayment when Medicare makes a
conditional payment, and the other payer
is determined to be primary.
State Health Insurance Assistance
Program(SHIP)—A state program that
gets money from the Federal government
to give free local health insurance
counseling to people with Medicare.
Workers’ Compensation—A plan that
employers are required to have to cover
employees who get sick or injured on the
job.
Workers’ CompensationMedicare Set-
Aside Arrangements (WCMSAs)
Account—An account set up with funds
from a Workers’ Compensation settlement
to pay for future medical and/or
prescription drug expenses which are both
related to the Workers’ Compensation
injury or illness/disease and would
otherwise be covered by Medicare.

34
 5
Section 5: Index

1-800-MEDICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 12, 15, 25, 32

Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 19
Black Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 29–30
Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 8, 19–27
COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 16, 30–32
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 15, 22, 29
Conditional Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 20–24
Copayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 22, 27
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 15, 22, 29
Denial of Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Disabled . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16–17
End-Stage Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18, 28, 31
Federal Black Lung Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 29–30
Group Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 8, 12–18, 30–32
Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–18
Initial Enrollment Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Large Group Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 16–17
Liability Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 19–22
Medicare Advantage Plans (Part C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 3
Medicare Coordination of Benefits Contractor . . . . . . 5, 8, 9, 22–24, 30, 32
Medicare Part A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Medicare Part B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2, 12
Medicare Part C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2, 3
Medicare Prescription Drug Coverage (Part D) . . . . . . . . . . . . . . . . . . 1, 2, 4
Medicare Secondary Payer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 12
Medigap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 12, 15 , 16, 32
Multi-Employer Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13, 17
No-fault Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 19–22
Original Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

35
 Section 5: Index

Pre-existing Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2
Primary Payer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 20
Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 7, 8, 12, 20, 29
Recovery Contractor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22, 24
Retiree Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 12–16
State Health Insurance Assistance Program . . . . . . . . . . . . . . . . . . 12, 15, 32
TRICARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 28–29
TRICARE for Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Veterans’ Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7, 26–28
Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7, 22–26
Workers’ Compensation Medicare Set-aside Arrangement . . . . . . . . . 24, 25

“Medicare and Other Health Benefits: Your Guide to Who Pays First” isn’t a legal
document. The official Medicare Program provisions are contained in the relevant
laws, regulations, and rulings.
The information in this booklet was correct when it was posted on www.medicare.gov.
To find out if the booklet is available in print, other formats, or if the information has
been updated, call 1-800-MEDICARE (1-800-633-4227). TTY users should call
1-877-486-2048.

36
Notes

37
 Notes

38
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850

Official Business
Penalty for Private Use, $300

CMS Product No. 02179

Revised April 2010

• Call the Medicare Coordination of Benefits Contractor at 1-800-999-1118 with

any changes in your insurance or any questions about who pays first. TTY users
should call 1-800-318-8782.

• ¿Necesita usted una copia en español? Llame GRATIS al 1-800-MEDICARE

(1-800-633-4227). Los usuarios de TTY deberán llamar al 1-877-486-2048.