If someone 65 and up has a health insurance plan in addition to Medicare, such as employee group coverage if they or their spouse is still working, or through a company retiree plan, who determines which one covers what, when and how much?

Each insurer is called a payer. As Medicare explains, in the case of multiple payers, there are rules determining who pays first (primary) and who pays the remainder of the cost(secondary) when you have other insurance.

Primary and secondary

Let’s say you have two health insurance plans and a doctor’s visit bill. Your primary will pay as much of it as the plan allows.

The secondary will then pay remaining costs, if any. Depending on the type of coverage, the secondary payer may or may not pick up all of the remaining balance.

Another thing to consider: if Medicare is your primary and your group health or retiree coverage is the secondary, the other insurance will not pay unless you are enrolled in Original Medicare Part B, which covers doctor visits.

Medicare conditional payments

If your other insurance company fails to pay a claim within a reasonable amount of time, it’s possible your healthcare provider will send Medicare the bill.

At that time, Medicare may make what’s called a conditional payment, so that you don’t have to pay out-of-pocket for the expense.

Medicare will typically seek to recover that payment later, since the other insurance was the primary and therefore, should have paid it to begin with. If you receive a settlement or other type of payment, you’ll need to reimburse Medicare yourself.

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