When having more than one health plan coverage, such as Medicare and health insurance, COB is a process that dictates who pays first (primary payer) for your medical costs and who pays second (secondary payer). 

If you’re someone who’s eligible for Medicare and also has another insurance plan, then knowing the rules of COB can save you lots of money. So what are those rules? Read this article to learn the key “ifs and buts”.

Medicare Coordination of Benefits rules

In 1971, the (NAIC) National Association of Insurance Commissioners issued its set of coordination of benefits Medicare guidelines. The model serves as an example for insurers and state legislatures to adopt a consistent set of Medicare COB rules. Let’s take a look at the takeaway points from the COB guidelines.  

• The primary plan needs to pay or provide its benefits as if the secondary plan or plans don’t exist. It means that the primary payer has to cover your healthcare cost up to the limits first, then the secondary payer will cover the remaining, if any, or pay its share to the maximum limit. 

In most cases, Medicare is the primary payer for individuals who are eligible for Medicare and have other insurance. However, it may vary in some scenarios, which we will discuss below.

• Both primary and secondary payers are expected to process and pay claims promptly without delaying payments due to COB processing.

• If there’s a dispute between your Medicare and healthcare insurer, then you can resolve the issue through some means. 

For instance, provide all the necessary documentation to both parties or opt for internal and external reviewing, where a third party reviews the case. However, if the dispute doesn’t end here, you can take legal action as the last resort. 

Now that we’ve discussed the certain COB rules set by the NAIC. Let’s see how Medicare works and coordinates with other insurance companies in different scenarios.  

Medicare COB scenarios – who pays first

In some cases, Medicare acts as a primary payer. While in other cases, it’s a secondary. In either case, there’s a Medicare COB contractor who acts as a referee and reviews the cases, then determines which one is going to pay first (primary) and which one will pay second.

Situations where Medicare pays first

• If you’re eligible for Medicare and have no other insurance coverage, Medicare is the primary payer for your healthcare services.
• If you’re suffering from ESRD but have enrolled in Medicare, it will save you quite some money. It will act as a primary payer for the first 30 months of ESRD eligibility.

Note: ESRD is a permanent kidney failure condition and requires ongoing dialysis or a kidney transplant. Without financial assistance, it can cost you an arm and a leg. So enrolling in Medicare would make sense.

• If you have retiree insurance from the previous job.
• If you’re 65 or older with employer group health coverage through your or your spouse’s employment, and your or their employer has less than 20 employees, then your Medicare pays first.
• If you’re 65 and disabled, have group health coverage through your or any family member’s current employment, and that employer has less than 100 employees, your Medicare has the primary responsibility. 
• If you’re enrolled in Medicare Advantage Plans (Part C), it’ll pay for your hospital and medical services as a primary payer. However, note that Medicare Advantage plans can have annual updates, so it’s always best to review it annually and contact the provider for any information.
• If, in addition to Medicare, you’re also enrolled in Federal insurance plans, such as Medicaid or TRICARE, Medicare will pay first. The remaining costs will be covered through the federal plans.

Situations where Medicare pays second

• If you’re 65 or older with health insurance coverage through your or your spouse’s current employment and the employer has more than 20 employees,
• If you’re under 65 and disabled, your or your family member’s current employment has your healthcare covered, and the employer has 100 or more employees, 
• If you go through medical care because of an accident, all the costs will be paid first by your auto insurance and or no-fault insurance,
• If you’re receiving workers’ compensation benefits that cover health care costs.

For more information about Medicare as a secondary payer, click here to dive deep into the detailed MSP guide.

How do I update Medicare Coordination of Benefits?

It’s very important to keep your Medicare COB information updated and accurate before your next medical visit. If by chance you haven’t, here’s what you should do.

1. Contact Medicare

First, pick up your phone and contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) and 1-877-486-2048 if you’re a TTY (for the hearing and speech impaired) user. Moreover, you can also visit the website at www.medicare.gov and log in to your Medicare account to make updates or changes.

2. Provide updated information

Next, if any changes occur in your health insurance coverage, including changes to your employer or union coverage, private insurance, or any other type of health coverage you have, inform your Medicare about it. 

3. Fill out the CMS- Coordination of Benefits Form

In exceptional cases, you may also need to fill out a Coordination of Benefits (COB) form provided by your Medicare. The form will collect information about your other insurance plans and help determine which plan pays first. 

4. Review and confirm information

Once you’ve provided all the information and filled out the forms, review them again to ensure all the information is true and accurate. This includes checking the insurance policy, the policyholder’s name (if it’s not you), and any changes in your employment or health insurance status.

5. Follow up

After sending the updates their way, make sure to keep follow-ups with your Medicare to confirm that the changes have been processed, and most importantly, your Coordination of Benefits is up-to-date.

6. Stay informed

Once your COB is updated, try to stay informed of any changes that may occur in your insurance plans. Whether you take any new insurance, drop an existing one, or have changes to your current coverage, always keep Medicare on speed dial.

7. Keep records

Last but not least, always keep records of any correspondence, forms, or documents related to your Coordination of benefits. It’s a good practice because you never know when you will find yourself in disputes and legal activities. Your past Medicare documents will come in handy in such dispute cases.

Medicare Coordination of Benefits phone number 

Benefits Coordination & Recovery Center (BCRC): 1-855-798-2627. For TTY users: 1-855-797-2627. Apart from holidays, their Customer Service representatives are available from Monday to Friday, 8 AM to 8 PM, Eastern Time.

Medicare Coordination of Benefits Form 

Click here to go to the official site, from where you can download the forms. However, know that Medicare forms and requirements may change over time. 

So, it’s best to go to www.medicare.gov, use the search bar to search for whatever forms you’re looking for, and download the up-to-date version of the form. 

FAQs 

Who is the best person to talk to about Medicare?

If you’re looking for any information regarding Medicare, the best source is their official website. Visit Medicare.gov or contact 1-800-MEDICARE (TTY users: 1-8770486-2048) and ask any questions you have in mind.

Do I still need Medicare if I have health insurance?

If you are near your retirement age and have a health insurance plan through your employer or another source, you may still want to enroll in Medicare, depending on your circumstances. 

For instance, if your or your spouse’s current employer has more than 20 employees and offers healthcare insurance, it pays first for your medical costs. So, in this case, you can choose to delay enrolling in Medicare. 

However, in case the employer has fewer than 20 employees, it’ll be your secondary health coverage. So, it’s advisable to enroll in a primary plan like Medicare.

Who pays first between Medicare and VA benefits?

You can get treatment under both Medicare and Veterans’ benefits programs. However, Medicare is never the secondary payer after the Department of Veterans Affairs (VA). Each time you get any healthcare service or see a doctor, you will choose which program, Medicare or VA benefits, covers the costs. 

Moreover, Medicare can’t pay for the same service that your Veterans’ benefits have covered already, and vice versa. On top of that, if you want to pay through VA benefits, you must go to a VA hospital/ facility or have the VA authorize services in a non-VA facility.