When it comes to healthcare, there’s plenty of head scratches and you’re often faced with more questions than answers. SENIORx Patient Advocates works hard to eliminate those questions and provide clear, informative guidance to help you with your healthcare woes. One such question we will address is when it comes to MEDICARE “coordination of benefits” – who pays first and how can you be sure you’re getting the coverage benefits you are entitled to and that your insurance pays?
To start, let’s define coordination of benefits (COB). In layman’s terms, coordinated benefits suggests that you’re covered by more than one insurance provider including Medicare. According to MEDICARE, the primary responsibility of the “BENEFITS COORDINATION & RECOVERY CENTER” (BCRC) is to protect the MEDICARE trust fund. MEDICARE needs to know if you have other coverage (such as employer or retiree, Workers Comp, Black Lung benefits, or even auto or home owner’s insurance where another insurance entity responsible for paying claims – before MEDICARE. COB will then “coordinate” coverage with the other insurer & may not pay first (or at all) for some or all claims. The BCRC will determine the answer to the question of “who pays first”. These are Federal rules & are not up for negotiation or interpretation. Claim payments to providers (hospitals, doctor offices, lab or imaging services, prescription, medical equipment, & others providing medical services) by MEDICARE &/or other insurers will be affected based on whether your COB status with MEDICARE is correct or not.
The process also allows for the sharing of your data with other payers to make the process as seamless as possible. This will require communication between private or group insurance carrier & the Benefits Coordination & Recovery Center (BCRC). If your insurance company does not have an agreement with the BCRC, it could be up to you to coordinate with your secondary or supplemental insurer. Additionally, it ensures that coverage from both insurers does not exceed 100% of the total claim and allows for coordination with any Part D (rx) benefits you may have.
Coordination of benefits is one of the most complex parts of MEDICARE. Most MEDICARE beneficiaries are not even aware that they may need to take action to communicate to the COB that employment status has changed (active employee to retiree) or that a Workers Comp claim closed several years ago & is no longer open. See the table below for some examples that might affect you!
The chart below outlines which insurance pays first in some of the most common instances where patients have coordination of benefits.
Other factors that may impact your benefit include the following:
- The coverage that pays first will pay up to its plan limit.
- The secondary coverage will pay only those costs not covered by the first, up to its limit or 100% of the cost.
- If your primary payer is Medicare and your employer is the secondary payer, it is necessary for you to join Medicare Part B before your employer-based insurance will pay secondary for Part B services (otherwise, they will only pay claims secondary as if you had Part B coverage)
- The following insurance types are usually the primary payer for their related services:
- No-fault insurance
- Black lung benefits
- Workers’ compensation
- Medigap (MEDICARE supplements) NEVER pay first if MEDICARE declines to pay
Most critical in managing “coordination of benefits” issues & ensuring you get the maximum benefits of your insurance involves informing MEDICARE when your insurance coverage &/or employment situation changes. Letting the BCRC know that another payer is responsible to pay claims as soon as possible, will save you much time, effort, worry, and frustration. Specialists at the BCRC will help you understand what information they need. Don’t wait to communicate with MEDICARE or the BCRC!
If you have further questions or are not sure where to find more information on this important topic, we are happy to walk you through the process. Additional information can be found by visiting our website www.seniorpatientadvocates.com or by contacting our office at 307-472-1770. We are certified insurance consultants who assist our clients in navigating the Medicare maze. We are YOUR Medicare advocate.