Medicare and Private Insurance: Can You Have Both?

Health insurance helps you pay for many types of medical expenses.

It is possible to have both private insurance and Medicare at the same time.

When you have both, a process called “coordination of benefits” determines which insurance provider pays first. This provider is called the primary payer.

Once the payment order is determined, coverage works like this:

1. The primary payer pays for any covered services until the coverage limit has been reached.
2. The secondary payer pays for costs that the primary payer doesn’t cover; however, it may not cover all costs.

The provider who is the primary payer can depend on the type of private insurance you have and your individual situation. In some cases, Medicare may be the primary payer, while in others, it may be the secondary payer.

There are several different situations when you may have private insurance and Medicare at the same time. This can happen if you have:

• Coverage through an employer: When you’re eligible for Medicare, you may still have private insurance through your employer.
• Coverage under your spouse’s private health insurance: You can have Medicare and also be covered on a group plan provided by your spouse’s employer.
• COBRA: COBRA allows you to temporarily keep private insurance coverage after your employment ends. You’ll also keep your coverage if you’re on your spouse’s private insurance and their employment ends.
• TRICARE: TRICARE provides coverage for active and retired members of the military and their dependents. You can have both TRICARE and Medicare if you:
  • are age 65 or over and enrolled in Medicare Part B
  • have a disability, end stage renal disease (ESRD), or amyotrophic lateral sclerosis (ALS) and are enrolled in both Medicare Part A and Part B
  • have Medicare and are a dependent of an active duty service member with TRICARE

Now that we’ve seen when you may have both Medicare and private insurance, let’s discuss who pays first in each situation.

You have private insurance coverage through your employer or a spouse’s employer

When you’re eligible for Medicare, you can still have private insurance coverage provided by an employer. Generally speaking, you’re eligible for Medicare when you:

• are age 65 or older
• have a qualifying disability
• receive a diagnosis of ESRD or ALS

How Medicare works with your group plan’s coverage depends on your particular situation, such as:

• If you’re 65 or older: In companies with 20 or more employees, your group health plan pays first. In companies with fewer than 20 employees, Medicare pays first.
• If you have a disability or ALS: In companies with 100 or more employees, your group health plan pays first. When a company has fewer than 100 employees, Medicare pays first.
• If you have ESRD: Your group health plan pays first during a 30-month coordination period. This is regardless of the company’s number of employees or whether you’re retired.

Your company may offer you coverage under a group plan after you retire. This is called retiree coverage. In this case, Medicare pays first, and your retiree coverage pays second.

Some health insurance plans, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans, require using in-network providers. If this is the case with your group health plan and it pays first, you may not be covered by Medicare if you choose to use an out-of-network provider.

You have COBRA

If you have both Medicare and COBRA, the provider that pays first depends on your specific situation, such as:

• If you’re age 65 or older or have a disability: Medicare pays first.
• You have a disability or ALS: Medicare pays first.
• You have ESRD: COBRA pays first. Medicare may pay second, depending on whether there’s an overlap between your COBRA coverage and your first 30 months of Medicare eligibility based on having ESRD.

You have TRICARE

If you have TRICARE, the provider that pays first depends on whether or not you’re on active duty:

• If you’re on active duty: TRICARE pays first for any services covered by Medicare. TRICARE also covers Medicare deductibles, coinsurance costs, and any services covered by TRICARE but not Medicare.
• If you’re not on active duty: Medicare pays first. TRICARE can pay second if you have TRICARE for Life coverage.

Working with both private insurance and Medicare can be a complicated process. If you have questions or concerns about what’s covered and which provider pays first, you can reach out to several sources, including:

• Medicare: You can contact Medicare using its general contact information or by contacting its Benefits Coordination and Recovery Center directly at 800-MEDICARE (800-633-4227; TTY: 877-486-2048).
• Social Security Administration (SSA): Contacting the SSA at 800-772-1213 can help you get more information on Medicare eligibility and enrollment.
• State Health Insurance Assistance Program (SHIP): Each state has its own SHIP that can aid you with any specific questions about Medicare.
• United States Department of Labor: If your employment has ended, you can contact the Department of Labor to learn more about COBRA coverage at 866-487-2365.
• TRICARE: Contacting TRICARE directly at 866-773-0404 may be beneficial when navigating coverage alongside Medicare.

In some situations, you can have both private insurance and Medicare, such as if you’re covered under private insurance through an employer.

When you have private insurance and Medicare, one provider will pay for healthcare services first, and the second may potentially cover the remaining costs.

This depends on your situation and the type of private insurance you have.

If you have questions about how Medicare works with private insurance, don’t hesitate to contact Medicare, the SSA, or your local SHIP for assistance.