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Coordination of Medicare And Other Health Benefits

Medicare and Group Health Insurance: Medicare and More Than One Group Policy

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Confusion can develop if you have Medicare and two group policies because Medicare's Coordination of Benefits is not identical with the private group insurance industry's Coordination of Benefits provisions.

Generally, Medicare rules will govern, but it may take some work to get each of the three entities to agree which will be primary.

Contact Centers for Medicare and Medicaid Services (CMS) and ask for guidance: tel. 877.267.2323 or in the Baltimore Area: 410.786.3000.

For example, Phoebe:

  • Is covered by Medicare.
  • Is also covered by her former employer who continues her coverage while she is disabled; and
  • She is also covered as a dependent under her spouse's plan.

Private industry rules say her employer's plan is primary when compared to the plan on which she is a dependent. However, under Medicare rules, her spouse's plan is primary because it is a plan obtained due to the "active, current employment" of her spouse.

In the real life situation in which this happened, both plans refused to pay first. Phoebe contacted a person in CMS's San Francisco office who contacted both insurance companies. The companies agreed to follow Medicare's rule, making her employer's plan primary.

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