Trying to figure out when Medicare is a primary or secondary payer is the number one concern for those who keep their employer coverage. Although the intersection of Medicare and group health insurance can be confusing, it’s important to carefully weigh out the pros and cons of having both insurances before you make any changes.

When Is Medicare Primary or Secondary?

Whether Medicare is considered primary or secondary coverage depends on the size of your employer and your specific situation:

1. Employers with 20 or More Employees:
   • If you are 65 or older and still working, your employer’s group health plan is the primary payer, and Medicare is secondary. This means your employer’s insurance pays first, and Medicare covers any remaining costs.
   • If you have a disability and are under 65, and your employer has 100 or more employees, the employer’s group health plan is primary, and Medicare is secondary.
2. Employers with Fewer Than 20 Employees:
   • If you are 65 or older and still working, Medicare is the primary payer, and your employer’s insurance is secondary. This means Medicare pays first, and your employer’s insurance covers any remaining costs.
   • If you have a disability and are under 65, and your employer has fewer than 100 employees, Medicare is the primary payer.
3. Retiree Coverage:
   • If you are retired and have retiree health coverage from a former employer, Medicare is primary, and your retiree plan is secondary.

Pros and Cons of Employer Insurance with Medicare

Pros:

1. Comprehensive Coverage: Combining employer insurance with Medicare can provide more comprehensive coverage, reducing out-of-pocket expenses.
2. Access to Network Providers: Employer plans often have established networks of providers, which can offer additional options for care beyond what Medicare alone may provide.
3. Additional Benefits: Employer plans may include benefits not covered by Medicare, such as dental, vision, and prescription drug coverage.
4. Cost Sharing: Some employer plans offer lower premiums or cost-sharing compared to Medicare alone, making healthcare more affordable.

Cons:

1. Higher Premiums: Maintaining both employer coverage and Medicare can lead to higher overall premiums, especially if your employer does not cover a significant portion of the insurance cost.
2. Coordination of Benefits: Navigating which insurer pays first can be complex, and mistakes in billing can lead to delays or denials in claims processing.
3. Coverage Overlap: There may be redundancy in coverage, leading to unnecessary expenses for duplicate benefits.
4. Limited Choices: Employer plans often have specific networks and formularies, which may limit your choice of providers and medications compared to the broader options available through Medicare.

Making the Right Choice

Deciding whether to keep employer coverage alongside Medicare involves weighing these pros and cons against your individual healthcare needs and financial situation. Here are some tips to help you decide:

1. Evaluate Your Health Needs: Consider your current health status, frequency of doctor visits, and prescription medication needs.
2. Compare Costs: Look at the premiums, deductibles, copayments, and out-of-pocket maximums for both options.
3. Check Provider Networks: Ensure your preferred healthcare providers and pharmacies are covered under both plans.
4. Seek Advice: Consult with your benefits administrator at work and a Medicare advisor to understand how the plans coordinate and what’s best for your situation.

Combining Medicare with employer group coverage can offer enhanced benefits and protections, but it requires careful consideration and planning.

For personalized guidance on navigating Medicare and employer insurance, contact us at 1-855-611-4856 today.