In our post Medicare & Group Health Coverage we discussed several scenarios to show which health coverage is primary and secondary when a person is both Medicare-eligible and covered by a group health plan through an employer.
But what happens when you leave the group plan and fully transition to Medicare Part A (hospital) and Part B (medical/outpatient), along with supplemental medical and drug coverage? Does the coordination get updated automatically without issues? Well, sometimes it’s fine and other times it requires some action on your part to update who is primary.
Medicare keeps a database on folks that have medical insurance benefits through other sources, such as an employer group health plan. But sometimes that data doesn’t get updated quickly enough when you transition to full Medicare coverage. This can cause Medicare to deny claims, as they might still think you have your group coverage that is usually in the primary coverage position.
This happens all the time…even if you provide the necessary insurance ID cards from your new insurance.
So here’s what you should do, based on whether you enroll in a Medicare Supplement (Medigap) plan…or…an all-in-one Medicare Advantage (Part C) plan:
If you enroll in a Medicare Supplement (Medigap) plan…
Primary: Original Medicare Parts A & B (your red, white, and blue Medicare card)
Secondary: Medicare Supplement (Medigap) plan
This is where we more commonly see Medicare beneficiaries have medical claims denied, because Medicare thinks it’s not the primary coverage. What you need to is call the Medicare Benefits Coordination & Recovery Center at (855) 798-2627. Explain to the representative that your claims are being denied, because Medicare thinks another plan is primary (your previous health insurance). The representative will ask you a series of questions to get the information updated in their systems. About 1-2 weeks later, you can have your medical providers resubmit the claims and everything should be okay moving forward.
If you enroll in a Medicare Advantage (Part C) plan…
Primary: Medicare Advantage plan provides Part A, Part B, and potentially Part D benefits
Secondary: N/A - just use Medicare Advantage plan, NOT your Medicare card
Typically, when you enroll in a Medicare Advantage plan, Medicare updates it’s database to reflect this change…and you don’t have to take any action to ensure claims are processed correctly.
But sometimes we see issues where Medicare still thinks you have your previous health insurance. If this happens, contact the Medicare Benefits Coordination & Recovery Center at 855-798-2627. Explain to the representative that your claims are being denied, because Medicare thinks another plan is primary to your Medicare Advantage plan. The representative will ask you a series of questions to get the information updated in their systems. About 1-2 weeks later, you can resubmit claims and everything should be okay moving forward.
NOTE: We hear on occasion that making this call doesn’t always fix the issue on the first try. Just be aware, you might have to do this twice to make it stick.
References:
Medicare.gov
Medicare & Other Coverage
How Medicare Coordinates With Other Coverage
Medicare Benefits Coordination & Recovery Center
