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In certain situations an employee can have coverage under both Medicare and an employer-sponsored group health plan. To help reduce the hospital and medical expense benefit payments made by Medicare, the federal government has passed laws to shift the burden to the private sector, particularly where people are still working. In general these laws seek to preclude employer plans from taking advantage of the existence of Medicare benefits and require that private sector employer plans pay their benefits regardless of the existence of Medicare benefits. |
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In general, there are four different types of scenarios involving Medicare and private health care coverage: |
Medicare coverage for people who are age 65 or older
Medicare coverage for people who are under 65 and who are disabled (employee, spouse or dependent)
Medicare coverage for people who also have retiree or other continued coverage under an employer sponsored health plan
Medicare coverage for people who qualify for Medicare due to kidney disease (ESRD), regardless of the age of the employee, spouse or dependent
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Health plans of Employer groups that are subject to the Age Discrimination in Employment Act (at least 20 full-time or part-time employees on the regular payroll) must comply with the Medicare Secondary Payer Rules. If the rules are not followed, significant fines and penalties can be imposed on both health plans and issuers.
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These Rules can be found in 42 CFR411 and in Sec. 1862(b) of the Social Security Act and 26 USC Section 5000.
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Link to Social Security Act Section 1862(b)
http://www.ssa.gov/OP_Home/ssact/title18/1862.htm.
Link to 42 CFR411
http://www.access.gpo.gov/nara/cfr/waisidx_05/42cfr411_05.html . See particularly Subpart E beginning at 411.100
To access 26 USC Section 5000 go to:
http://www.gpoaccess.gov/uscode/index.html and enter 26USC5000 in the search field
The links below will take you to additional information on the Centers for Medicare and Medicaid website:
Medicare Publication: Medicare and Other Health Benefits: Your Guide to Who Pays First
http://www.medicare.gov/Publications/Pubs/pdf/02179.pdf
Medicare Publication: Medicare Coverage of Kidney Dialysis and Kidney Transplant Services
http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf
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