Medicare’s Coordination of Benefits and Recovery

What does ‘coordination of benefits’ mean in Medicare?

If you have two healthcare plans, one of which is Medicare, Medicare is usually the primary payer. This applies, for example, when a group health plan insures you through an employer with 20 employees or fewer or under COBRA, which is a law that helps protect your healthcare rights.

That said, there are times when Medicare might become the secondary payer. This happens when your employer has more than 20 employees, or you have a disability and a plan through an employer with more than 100 employees.

Some other scenarios can include living with end stage renal disease (ESRD) and being within the first 30 months of your eligibility for Medicare.

In addition, Medicare may pay second if you have an accident involving no-fault or liability insurance or workers’ compensation covers you.

How does recovery work with the coordination of benefits?

The Centers for Medicare & Medicaid uses the BCRC to identify when you have another insurance plan besides Medicare.

At times, after Medicare pays your claim first, the BCRC learns new information that means your group health plan should have been the primary payer. In this case, the Commercial Repayment Center recovers the funds from the employer and the group health plan.

The Commercial Repayment Center also recovers mistaken payments when you’re self-insured or when liability insurance, no-fault insurance (personal injury protection insurance), or a workers’ compensation provider is involved.

What should I know about Medicare’s coordination of benefits?

Coordination of Benefits and Recovery can be a complex process. That said, as the insured, it’s still important for you to have a general understanding of how this process works.

It’s key to remember that when you have two types of insurance, the primary payer takes care of your costs up to its coverage limits. If you still have remaining expenses afterward, the secondary payer will cover these. However, the secondary payer, which might be Medicare, may not cover every remaining cost.

In addition, if Medicare is your primary insurance and your employer’s plan is secondary, you may need to be enrolled in Original Medicare’s Part B plan, as opposed to a Medicare Advantage plan with similar coverage, before your employer’s insurance can help cover Part B services.

Other facts to remember include:

• If you’re a dual Medicaid and Medicare enrollee, Medicaid will always be the secondary payer.
• If you’re in the military and have Medicare, TRICARE is the primary payer for Medicare services.
• If your other plan is part of a multiple-employer plan, only one of these plans needs to have the required employee count for the group health plan to be the primary payer.

Lastly, it’s important to notify Medicare if your other health insurance plan changes.

How do I contact Medicare’s Coordination of Benefits and Recovery?

If you’re not sure which insurer should pay first, you can check your other plan’s insurance policy or coverage details.

You can also contact your employer or union benefits administrator or call the BCRC at 855-798-2627 (TTY 1-855-797-2627).

In addition, if you disagree or believe an error with Medicare and your other insurer divided your coverage, you can file an appeal. Information on the appeal process is available on Medicare.gov.

Takeaway

The Medicare Secondary Payer program assists Medicare in identifying situations in which it should not be the primary payer for medical claims.

As part of that, the BCRC and CRC work together to determine the order in which your two insurers are responsible for payment and recover funds when this distribution was handled incorrectly.

Knowing how this process works can help you better understand how your medical bills are paid when you have both Medicare and a private insurance plan.