When your client has Medicare and another form of health insurance, understanding who pays first can make all the difference in avoiding surprise bills and ensuring proper coverage.
Whether they’re still working, covered under a spouse’s plan, or enrolled in a retiree policy, the order of payment—called coordination of benefits—matters. Here’s what agents need to know.
The Basics: What Is Primary vs. Secondary Payer?
When someone has more than one insurance, one becomes the primary payer (pays first), and the other becomes the secondary payer (pays second). The primary insurer pays up to the limits of its coverage. The secondary may cover remaining eligible costs.
The coordination depends on the client’s employment status, age, and type of group health coverage.
If Your Client Is 65+ and Still Working (or Covered by a Working Spouse)
✅ Employer Has 20 or More Employees:
- Primary Payer: The group health plan pays first.
- Secondary Payer: Medicare pays second.
- 🧾 Tip: Providers bill the group plan first, then send remaining balances to Medicare. Clients are responsible only for what’s not covered by either.
✅ Employer Has Fewer Than 20 Employees:
- Primary Payer: Medicare pays first.
- Secondary Payer: The group health plan pays second.
- ⚠️ Exception: If the plan is part of a multi-employer or multiple employer group health plan, Medicare may pay second—only if another employer in the group has 20+ employees.
Important Reminders for Agents
- Verify who pays first: Always contact the employer plan directly to confirm how they coordinate with Medicare.
- Medicare Part B requirement: If the group or retiree plan is the secondary payer, the client must enroll in Medicare Part B for the secondary coverage to apply.
- Equal coverage mandate: Employers with 20+ employees must offer the same benefits to employees (and spouses) 65+ as they do to younger employees.
Pro Tip for Agents
This topic can be confusing for clients, especially those working past 65 or managing dual coverage through a spouse’s employer. Use clear language to explain the order of payment and help them avoid coverage gaps.
When in doubt, consult the benefits coordinator at their employer—or let us help you navigate the details.
Final Thought
Knowing how Medicare coordinates with employer plans isn’t just a technical detail—it’s a critical part of getting the right care at the right price. A quick check now can save your clients hundreds later.
📞 Need help sorting out primary vs. secondary coverage?
National Insurance Markets is here to support you and your clients. Give us a call today.
