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Understand which insurance pays first

If you have more than one insurance which covers the same health care expenses, then one insurance will pay its benefits as the primary payer. Any remaining balance may be paid in part or full by your other insurance.

Use Medicare’s who pays first tool to check which one of your health coverage is primary when you have Medicare.

Avoid billing errors, by telling your FEHB plan that you have Medicare. As soon as you enroll in Medicare, let your FEHB plan know that you or a covered family member has Medicare coverage.

How it works

  • When the primary payer doesn’t cover a particular service, but the secondary payer does, the secondary payer will pay as the primary payer.
  • The secondary payer may not pay the full remaining cost. In this case, you must pay any remaining billed amount.

Medicare rules determine whether Medicare or FEHB is primary in any given scenario.

  • If Medicare is primary, Medicare automatically transfers claims information to your FEHB plan once your claim is processed. You generally don’t need to file a claim with both.
  • You will receive an Explanation of Benefits (EOB) from your FEHB plan and a Medicare Summary Notice (MSN) from Medicare.
    • If you must file with the secondary payer, send the EOB or MSN you receive from the primary payer.
    • In most cases, your services will be paid in full by Medicare and your FEHB plan.

When is FEHB the Primary Payer?

  • Active employment. You are an active Federal employee or reemployed annuitant eligible for FEHB and either you or your covered spouse has Medicare
  • Onset of End Stage Renal Disease. Your FEHB plan is primary for the first 30 months of eligibility or entitlement to Part A regardless of your employment status
    • Exception: if you already had Medicare and it was the primary payer on the day before you became eligible for Medicare Part A due to ESRD, then Medicare will continue to be primary
  • You are under age 65, entitled to Medicare based on disability, and covered under FEHB
  • Receiving Workers’ Compensation. You are a federal employee receiving workers’ compensation and determined unable to return to duty
    • Exception: FEHB is not the primary payer for claims related to the workers’ compensation injury or illness

When is Medicare the Primary Payer? 

  • Annuitant. You are an annuitant and either you or your covered spouse has Medicare
    • Exception: if you’re a reemployed annuitant eligible for FEHB
  • Federal judge or Tax Court judge. A Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (Or your covered spouse is this type of judge)
  • Onset of End Stage Renal Disease. Medicare will continue to be primary during the 30-month coordination period if it was the primary payer prior to the onset of ESRD
    • Exception: if Medicare was secondary prior to the onset of End Stage Renal Disease, it will continue to be secondary until the 30-month coordination period has expired
  • Expiration of the 30-month coordination period for ESRD. Medicare will be primary regardless of your employment status

Other health coverage

TRICARE or CHAMPVA: For annuitants, Medicare pays first for Medicare covered services and then FEHB, then TRICARE. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

  • When you turn 65, you must enroll in Medicare Part A and Part B to keep Tricare. 

Medicaid: Medicaid is a federal and state program that assists low-income individuals in paying for healthcare. You may have Medicaid, Medicare, and FEHB coverage. Medicaid pays last when you have other health coverage.

In other words, as an active employee, your FEHB coverage is primary, then Medicare, and Medicaid pays last. If you’re an annuitant, Medicare pays first, then FEHB, and then Medicaid.

  • If you’re an annuitant, you can suspend your FEHB coverage and avoid paying the FEHB premium while you have Medicaid.
  • Check your state’s Medicaid eligibility rules to learn if you must enroll in Medicare to continue receiving Medicaid benefits.

Examples

Scenarios you may experience or have questions about.

You are covered under PSHB and receive workers’ compensation benefits and determined unable to return to duty. Your PSHB coverage is primary and pays benefits first except for expenses related to your workers’ compensation injury or illness. Medicare is your secondary coverage and doesn’t pay for services covered by workers’ compensation.

You are retired military and have TRICARE and Medicare coverage and get FEHB coverage as spouse of a federal employee. Your FEHB coverage is primary, then Medicare, then TRICARE.

You are an annuitant covered by FEHB, Medicare, and Medicaid. You decide to suspend your FEHB coverage to save money by not having to pay the FEHB premium. You can later re-enroll in FEHB during Open Season or if you lose your Medicaid coverage not by choice.

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