Does my company insurance work with Medicare?

on Jun 13, 2024

Dear Toni,

I am 67 and have group health insurance through my current employer, with a high deductible. My question is, should I have also enrolled in Medicare, even though I am still working? If so, who pays my claims first? I have talked with friends, my company’s HR department, their insurance agent and get answers from “I don’t know” to “I’m not sure but I think … .” I cannot get a straight answer.

I have just started following your Medicare column in our local paper and am finding you are answering questions about Medicare problems I never knew I could have. Thank you!

--Rhonda from Dallas

Hello Rhonda,

Most answers about enrolling in Medicare can be found in the Medicare & You Handbook. Some people do not take Part B during their Initial Enrollment Period when turning 65, because they or their spouses are still working and have insurance from a current employer.

Let’s start by discussing enrollment in Medicare Part B when working full-time with an employer group health plan. Page 19 of the 2024 Handbook discusses “Should I Get Part B” with employer or union coverage and states: “If you or your spouse … are still working and you have health coverage through that employer or union, go to page 21 to find out how your coverage works with Medicare. You can also contact the employer or union benefits administrator for information. This includes federal or state employment and active-duty military service. It might be to your advantage to delay Part B enrollment while you still have health coverage based on your or your spouse’s current employment.”

When there's more than one payer, the "coordination of benefits" rule decides who pays first. The "primary payer" pays what it owes on your first bill, and then sends the rest to the "secondary payer." You, however, are still responsible for your deductible, whether it is Medicare’s deductible or your company insurance deductible.

How your coverage works with Medicare, according to Page 21 of the Medicare & You Handbook, depends primarily on how many employees are on your or your spouse’s employer group health plan. To summarize:

1. If your employer has 20 or more employees, your group health plan will generally be the primary payer. Enrollment in Part B is optional. If Medicare is a secondary payer and if you see a provider outside your employer’s insurance network, it is likely that neither the company plan nor Medicare will pay. (The employer must offer their employees 65 and older the same health benefits, under the same conditions, they offer employees under 65.)

2. If your employer has fewer than 20 employees, Medicare pays first. Always check with your human resources department or group health insurance agent to confirm whether it is necessary to enroll in Medicare Parts A and/or B.

Remember that the 6-month Medicare Medigap/Supplement Enrollment period begins when one first enrolls in Medicare Part B.

When you leave your or your spouse’s employer group health plan, you can enroll in Medicare Part B under a Special Enrollment Period (SEP). CMS Form L-564 “Request for Employment Information” is available for the employee and spouse enrolling in Medicare Part B past 65, to avoid Medicare’s Part B penalty upon leaving employer insurance.

Employees should visit Social Security as soon as possible to enroll in Medicare when their work status changes from full-time to part-time employee, when they decide to retire, or are terminated and enrolled in COBRA. Employees will not qualify for Special Enrollment if they have COBRA or retiree insurance and wait too long.

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Toni King is an author and columnist on Medicare and health insurance issues. She has spent nearly 30 years as a top sales leader in the field. For a Medicare checkup, call the Toni Says call center at (832) 519-8664 or email info@tonisays.com regarding your Medicare plans and options. Toni Says Medicare Survival Guide Advanced edition is available at www.tonisays.com. Toni’s Medicare Moments articles have just been released: https://familytalktoday.com/medicare-moments.