UNITED STATES—Toni, I am 67 and have group health insurance through my current employer. I have talked with friends, my company HR, and my insurance agent. I am receiving answers from “I don’t know” to “I’m not sure but I think …” My company health insurance has a $2,500 deductible. If I have a medical claim and I have Medicare Part A and my employer medical insurance, who will pay the claim first and how much will I have to pay?  Also, should I have enrolled in Medicare Part B since I am still working?

I have just started following your Medicare column in our local paper and am finding you are answering problems, I never knew I could have. Thank You so much. Roxanne, New Orleans.

Roxanne, let’s start with discussing enrolling in Medicare Part B when working with an employer group health plan.  On page 22 of the 2018 Medicare & You handbook, it discusses “Should I Get Part B” with employer or union coverage and states… “If you or your spouse is still working, and you have health coverage through that employer or union, contact your employer or union benefits administrator to find out how your coverage works with Medicare… It might be to your advantage to delay Part B enrollment.”

To answer about enrolling in Medicare Part B, it is optional because when you leave your or your spouse’s employer group health plan, then you can enroll in Medicare Part B with a Special Enrollment Period.

Now let’s talk about who will pay your claim first and this depends on how many employees are on your company’s group health plan:

1)       Your employer has 20 or more employees. Your group health plan will generally be primary. Should your group health plan not pay all the bill, you may need to ask the health care provider or your doctor to send the remainder of the bill to Medicare if you are enrolled in Medicare Parts A and/or B for secondary payment. Should there be any cost your health insurance or Medicare didn’t cover, you will have to pay the balance.

Your employer has 20 or more employees.  The employer must offer their employees 65 and older the same health benefits, under the same conditions that the company offers employees under 65. If the employer offers coverage to under 65 employees’ spouses, the employers must offer over 65 employees’ spouses the same coverage.

Medicare will generally pay second if the following applies:

  • If your employer joins forces with other employers or employer organizations i.e., unions, to sponsor a multi-employer plan (group health plan). Sometimes employers with less than 100 employees will band together to form a multi-employer plan. Medicare pays second.

2)       Your employer has less than 20 employees. Medicare pays first.

3)       You and Retiree Insurance (insurance from your or your spouse’s former employer): Medicare pays first.

Always verify with your Human Resources if the Insurance Company will pay first when the employees or employees’ spouses are over 65 and on company health benefits. One thing to know is that if you should go outside your employer’s network, it is possible that neither the company’s plan nor Medicare will pay.

Is the maze of Medicare confusing you? Call the Toni Says® Medicare hotline at 832-519-8664 or visit the Medicare Annual Enrollment Toni Says® webinars which explain what Medicare is and how to properly find your Medicare Part D plan at www.tonisays.com.

Toni King, author of the Medicare Survival Guide® is giving a $5 discount on the Medicare Survival Guide® Advanced book to Toni Says Medicare column readers.