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When you have other insurance and Medicare, who pays first and when?

If your client is 65 or older and has group health plan coverage based on their or their spouse's current employment status:

If the employer has 20 or more employees, then the group health plan pays first, and Medicare pays second. If the group health plan didn't pay all of your bill, the doctor or health care 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.
Employers with 20 or more employees must offer current employees 65 and older the same health benefits under the same conditions that they offer employees under 65. If the employer offers coverage to spouses, it must offer the same coverage to spouses 65 and older that they offer to spouses under 65.
If the employer has less than 20 employees and isn't part of a multi-employer or multiple employer group health plan, then Medicare pays first, and the group health plan pays second.
If the employer has less than 20 employees, the group health plan pays first, and Medicare pays second if both of these conditions apply:
- The employer is part of a multi-employer or multiple employer group health plan
- At least one of the other employers has 20 or more employees

Check with their plan first and ask if it will pay first or second. If your group health plan or retiree coverage is the secondary payer, you'll likely need to enroll in Medicare Part B before they'll pay.

Learn more:

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You joined a Medicare Advantage Plan or Program of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decide you want to switch to a Medicare Supplement and Part D Prescription Drug Plan. *Tip: If you enrolled after the age of 65, this does not apply to your situation.

You dropped a Medigap policy to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time, you’ve been in the plan less than a year, and you want to switch back. *Tip: You must switch back to your prior plan, unless it isn’t available.

In both circumstances, you have 63 calendar days after your coverage ends to make your changes.

Special Enrollment Periods: https://www.medicare.gov/basics/get-started-with-medicare/get-more-coverage/joining-a-plan/special-enrollment-periods

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When writing a Medicare Supplement with a guarantee issue right Medicare set a rule allowing you to automatically purchase without underwriting for Medigap Plan A, B, C, D, F, G, K or L that’s sold in your state by any insurance company.

Exceptions to the rule:

Plans C and F are no longer available to people new to Medicare on or after January 1, 2020.
However, if you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy Plan C or Plan F. People new to Medicare on or after January 1, 2020, have the right to buy Plans D and G instead of Plans C and F.
Some carriers can offer additional plan letters at their discretion.

*Note that most Medicare Supplement plans pay less in commission when a guaranteed issue right is being used.

Choosing a Medigap Policy Guide

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For 2024, some Medicare Advantage plans will have a Medical Deductible that members pay for covered services before the plan benefits apply. Services that count toward the deductible vary by plan.

Amounts paid toward the deductible do count toward the out-of-pocket maximum (MOOP)
Premiums, cost sharing for ancillary benefits and Rx costs do not count toward the deductible or MOOP
Deductibles do not apply to preventive, emergency or urgently needed services
A plan’s Rx deductible is separate from the medical deductible
Members who have Medicaid do not pay the plan deductible
When there’s a medical deductible for both in-network (INN) and out-of-network services (OON), it is a combined deductible amount
Important: Diagnostic mammograms and colonoscopies are not subject to the medical deductible

UHC creates great guides. You will see us use them often for educational purposes like the one linked below.

See deductible overview

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Original Medicare Enrollment: https://www.ssa.gov/medicare/sign-up

Part A and B Enrollment Forms

CMS-18-F-5: Individuals who do not have Part A and wish to enroll should complete the CMS-18-F-5 form or contact Social Security at 1-800-772-1213. This form can be used to enroll in Part B at the same time. If applying for the SEP for the Working aged and Working Disabled, also complete the form CMS-L564.

CMS-40B: Individuals who have Part A, but not Part B, should complete form CMS-40B to enroll in Part B. If applying for the SEP for the Working aged and Working Disabled, also complete the form CMS-L564.

CMS-4040: Individuals who are NOT entitled to social security or railroad retirement board benefits should complete form CMS-4040 to enroll in Part B.

CMS-43: Individuals who have ESRD should complete form CMS-43 to enroll in Part A and Part B.

CMS-10797: Individuals who qualify for a special enrollment period due to exceptional conditions should complete the CMS-10797 to enroll in premium Part A and Part B.

CMS-L564: Individuals who are applying for the SEP for the Working Aged and Working Disabled should complete the form CMS-L564 along with the applicable Part A or Part B enrollment form.