Who pays first? (2024)

Your answer:

Medicare pays up to the limits of its coverage since that’s your only health coverage.

Learn About Medicare Coverage

Your answer:

If you have Medicare because you’re 65 or older, Medicare pays first.

If you have COBRA and you’re eligible for Medicare:

• COBRA may only pay a small portion of your medical costs
• You may have to pay most of the costs yourself.

Contact your COBRA plan and ask what percent they pay.

What else do I need to know?

There may be reasons why you should take Medicare drug coverage instead of, or in addition to, COBRA. If you take COBRA and it includes creditable prescription drug coverage, you'll have a Special Enrollment Period to join a Medicare drug plan without a penalty when COBRA ends.

Learn About COBRA

Your answer:

Medicare pays first, and your (or your spouse’s) group health plan pays second.

Retiree coverage might not pay your medical costs during any period when you were eligible for Medicare but didn't sign up for it. When you become eligible for Medicare, you may need to sign up for both Part A and Part B to get full benefits from your retiree coverage.

What else do I need to know?

Check with your retiree coverage to find out if you’ll lose retiree benefits (including any non-drug health coverage) for yourself and/or your spouse or dependents if you get Medicare drug coverage. If you don’t understand how Medicare drug coverage will affect your current retiree drug and health coverage, call your benefits administrator.

If you have drug coverage through your current or previous employer, your employer or union will notify you each year to let you know if your drug coverage is creditable. Keep this information for your records.

• If your drug coverage is creditable, you can wait to join a Medicare drug plan and not pay a penalty if you don’t go without creditable prescription drug coverage for 63 days.
• Federal Employee Health Benefits Program plans include creditable prescription drug coverage, so you don’t need to get Medicare drug coverage. However, if you decide to get Medicare drug coverage, you can keep your FEHB plan, and in most cases, Medicare will pay first.

If you aren’t sure how your retiree coverage works with Medicare, get a copy of your plan’s benefit materials, or review the summary plan description your former employer or union gave you. Call your former employer’s benefits administrator for more information about how the retiree plan pays when you have Medicare.

Your answer:

The group health plan pays first, and Medicare pays second.

What if my plan has opted out?

If the group health plan didn't pay your entire bill, your provider should send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn't cover.

Note: If you’re in a Health Maintenance Organization (HMO) Plan or an employer Preferred Provider Organization (PPO) that pays first, and you get services outside the group health plan’s network, it's possible that neither the plan nor Medicare will pay. Before you go outside the plan’s network, call your plan to find out if it will cover the service.

What else do I need to know?

Call your benefits administrator before you make any changes or sign up for Medicare drug coverage.

If you have employer or union coverage and get Medicare drug coverage, you may lose your employer or union health and drug coverage (for you and your dependents). If this happens, you may not be able to get your employer or union coverage back. This is true even if you get Extra Help.

Your Answer

Medicare pays first, and the group health plan pays second.

Call your benefits administrator before you make any changes or sign up for Medicare drug coverage.

If you have employer or union coverage and get Medicare drug coverage, you may lose your employer or union health and drug coverage (for you and your dependents). If this happens, you may not be able to get your employer or union coverage back. This is true even if you get Extra Help.

Your answer:

Learn how Medicare coverage works if you have End-Stage Renal Disease.

Your answer:

You aren’t covered by Medicare yet. Your group health plan is your only payer.

Learn more about getting Medicare before 65.

Your answer:

Medicare pays first, and the large group health plan pays second.

Note: When an employer has 100 or more employees, the health plan it offers is called a “large group health plan.”

Your answer:

Workers’ compensation pays first for items or services (including drugs) related to the workers’ compensation claim.

Medicare can’t pay for items or services that workers’ compensation will pay for promptly or if:

• The claim falls under an open ongoing responsibility for medicals case
• There’s an open Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA)

However, Medicare may make a conditional payment if the workers’ compensation insurance company denies payment for your medical bills, pending the insurance company’s review of your claim. What’s a conditional payment?

Note: This isn’t the same situation as when your workers’ compensation case has been settled and you’re using funds from your Workers’ Compensation Medicare Set-aside Arrangement to pay for your drugs and medical care that are related to your work illness or injury. The conditional payment rules don’t apply to an open and active ongoing responsibility for medicals case, nor do they apply to open Workers’ Compensation Medicare Set-aside Arrangement, accident, and injury cases.

What else do I need to know?

If Medicare pays for medical or drug claims before knowing that the claims are related to your workers’ compensation settlement, Medicare must be repaid from the Workers’ Compensation Medicare Set-aside Arrangement.

• If you're enrolled in Original Medicare, the Benefits Coordination & Recovery Center will investigate claims and request repayment from you.
• If you're enrolled in a Medicare Advantage or a Medicare drug plan, the plan will contact you to investigate claims and request repayment.

You're responsible for cooperating with the Benefits Coordination & Recovery Center, Medicare Advantage, or Medicare drug plan’s efforts to verify if claims are related to your workers’ compensation settlement and repay Medicare for those claims from your Workers’ Compensation Medicare Set-aside Arrangement.

What if I have a Medicare-approved Workers' Compensation Medicare Set-aside Arrangement amount?

Your answer:

It depends on the types of insurance or coverage you have.

Check with each of your types of insurance or coverage to get information about who pays first.

You can also call the Benefits Coordination & Recovery Center at 1-855-798-2627. TTY users can call 1-855-797-2627.

Your answer:

Your no-fault insurance or liability insurance pays first and Medicare pays second for services related to the accident or injury.

If your provider knows you have a no-fault or liability insurance claim, they must try to get paid by the insurance company before billing Medicare. If your accident or injury is an open ongoing responsibility medicals case, then the liability or no-fault insurance must pay first. However, if your liability or no-fault case doesn’t get ongoing responsibility for medical expenses, processing your bill may take a long time.

What happens if the no fault or liability insurance denies my medical bill, or is found not liable for payment?

What else do I need to know?

If the insurance company doesn't pay the claim promptly, your provider may bill Medicare. Medicare may make a conditional payment to pay the bill, and then will recover any payments the primary payer should have made later. What’s a conditional payment?

If Medicare pays for medical or drug claims before knowing that the claims are related to your workers’ compensation settlement, Medicare must be repaid from the Workers’ Compensation Medicare Set-aside Arrangement.

• If you’re enrolled in Original Medicare, the Benefits Coordination & Recovery Center will investigate your claims and request repayment from you.
• If you’re enrolled in a Medicare Advantage or a Medicare drug plan, the plan will contact you to investigate claims and request repayment.

You’re responsible for cooperating with the Benefits Coordination & Recovery Center, Medicare Advantage, or Medicare drug plan’s efforts to verify if claims are related to your workers’ compensation settlement.

Your answer:

If you have (or can get) both Medicare and Veterans’ benefits, you can get treatment under either program.

Generally, Medicare and the U.S. Department of Veterans Affairs (VA) can’t pay for the same items or services. Each time you get health care or visit a provider, you’ll have to choose which benefit to use.

Who pays, Medicare or VA?

• Medicare pays for Medicare-covered items and services.
• The VA pays for VA-authorized items or services in a VA or non-VA facility.
• If the VA authorizes services in a non-VA hospital but didn’t authorize all of the services you get during your hospital stay, then Medicare may pay for any Medicare-covered services the VA didn’t authorize.

What else do I need to know?

You may be able to get drug coverage through the VA program. You may also join a Medicare drug plan, but if you do:

• You can’t use both types of coverage for the same drug at the same time.
• You won’t be able to use the Department of Veteran Affairs “Meds by Mail” program.

Learn more about VA benefits and other insurance.

Your answer:

It depends whether you’re on active duty and where you get your items or services.

• If you're on active duty and have Medicare, TRICARE pays first for Medicare-covered services or items, and Medicare pays second.
• If you aren’t on active duty, Medicare pays first for Medicare-covered services, and TRICARE may pay second.
• If you get items or services from a military hospital or clinic, or any other federal health care provider, TRICARE pays. Medicare usually doesn’t pay for services you get from a federal health care provider or other federal agency.

What else do I need to know?

• Most people with TRICARE who are entitled to Part A must also have Part B to keep their TRICARE drug benefits. If you have TRICARE, you don’t need to join a Medicare drug plan. However, if you do, your Medicare drug plan pays first, and TRICARE pays second.
• If you join a Medicare drug plan, TRICARE and your plan may coordinate their benefits if your plan’s network pharmacy is also a TRICARE network pharmacy.

Get TRICARE Information

Your answer:

It depends on whether you have a tribal or non-tribal health plan. If you have a non-tribal health plan, it also depends on how many employees your employer has.

• If you have non-tribal group health plan coverage through an employer who has 20 or more employees, the non-tribal group health plan pays first, and Medicare pays second.
• If you have non-tribal group health plan coverage through an employer who has fewer than 20 employees, Medicare pays first, and the non-tribal group health plan pays second.
• If you have health insurance through a tribal health plan, Medicare pays first and the tribal health plan pays second.

What else do I need to know?

• If you get drugs through an Indian health facility, you’ll continue to get them at no cost to you, and your coverage won’t be interrupted.
• Many Indian health facilities participate in the Medicare Part D drug program. Joining a Medicare drug plan or Medicare Advantage Plan with drug coverage may help your Indian health facility because the plan pays the Indian health facility for the cost of your drugs.
• Talk to your local Indian health benefits coordinator who can help you choose a plan that meets your needs and tell you how Medicare works with the Indian health care system.

Find IHS Facilities

Your answer:

For any health care, including drugs, related to black lung disease, the Federal Black Lung Program pays first, if the program covers the service. 

Medicare won't pay for doctor or hospital services or drugs covered under the Federal Black Lung Program.

What else do I need to know?

Your provider should send all bills for the diagnosis or treatment of black lung disease to:

Federal Black Lung Program
P.O. Box 8302
London, KY 40742-8302

For all health care not related to black lung disease, Medicare pays first, and your doctor or health care provider should send your bills directly to Medicare.

If the Federal Black Lung Program won't pay your bill, ask your doctor or other health care provider to send Medicare the bill. Also ask them to include a copy of the letter from the Federal Black Lung Benefits Program explaining why they won’t pay your bill.

If you have questions about the Federal Black Lung Program, call 1-800-638-7072.

Get Program Information

Your answer:

Generally, Medicare pays first.

Medicaid never pays first for services Medicare covers. In rare cases where there’s other coverage besides Medicare, Medicaid pays after the other coverage has paid.

Learn more about how Medicare works with Medicaid.

What else do I need to know?

• Medicare will cover your drug costs. You'll need to join a separate Medicare drug plan or a health plan with Medicare drug coverage for Medicare to pay for your drugs. Medicaid pays for a limited number of drugs that that are excluded from Medicare Part D coverage.
• If you don't join a drug plan, Medicare will enroll you in one to make sure you don't miss a day of coverage.
• If you have full coverage from Medicaid and live in a nursing home, you pay nothing for covered drugs. Long-term care pharmacies contract with Medicare drug plans to provide drug coverage to their residents.
• If you have full coverage from Medicaid and live in an assisted living or adult living facility, or a residential home, you'll pay a small copayment for each drug.