Medicare and employer-based coverage


By Kay Kaylor
PREVIEW Columnist
I advocate for residents in extended care and assisted living residences as the region’s lead long-term care ombudsman. I also am a Senior Medicare Patrol (SMP) and State Health Insurance Assistance Program (SHIP) counselor. Information on the many aging and care concerns will be included here.
Medicare is complicated and it’s even more so for employees and their families who have job-based insurance or for people with retirement insurance. One of the most important things to know for both medical providers and Medicare beneficiaries is who pays first. The primary payer covers most of the medical bill, while the secondary pays after the primary insurer, often including copays and deductibles.
If the wrong insurance is billed first, the other insurer may not pay, but all people with Medicare have the right to appeal decisions. For those age 65 and older with job-based insurance, Medicare is the primary payer if the employer has fewer than 20 employees. The job-based insurance pays first if the employer has 20 or more employees.
In contrast, for people under age 65 with Medicare after collecting Social Security Disability for 24 months, Medicare pays first when an employer has fewer than 100 employees. Medicare usually pays first for people who qualify for Medicare with retiree insurance, with the retirement insurance secondary.
If the job-based insurance is primary, people may decide to delay enrollment in Medicare to avoid paying the Part B premium (currently $144.60/month). If Medicare is supposed to be primary, the job-based insurance may not cover expenses if the employee does not have Part B.
Even more confusing is COBRA coverage, which usually ends when Medicare begins, but Medicare would pay first. COBRA is not obligated to keep people enrolled once they are eligible for Medicare. Those already with Medicare must be allowed to enroll in COBRA, and then Medicare pays first and COBRA second. Other directives apply to COBRA coverage, depending on the situation.
Special enrollment periods exist for people who lose their job-based coverage. Other specific Medicare who-pays-first and Parts A and B enrollment rules apply for people with Federal Employee Health Benefits, a health savings account, end-stage renal disease, veterans affairs benefits and TRICARE for Life. Fortunately, the Medicare Rights Center has provided guidelines for SHIP and SMP counselors.
SJBAAA offers resources for people age 60 and older or on Medicare. For further information, please call 264-0501 or send an email to