A Primer for Employers on Medicare Coordination of Benefits
March 24, 2023
A Primer for Employers on Medicare Coordination of Benefits

When a plan participant or beneficiary has Medicare and other health insurance, such as group health plan insurance, retiree coverage or Medicaid, there can often be confusion as to which insurance pays first on claims. Coordination of Benefits (COB) rules, which are specified in plan documents or insurance policies, decide which insurance pays first. One plan is considered the primary payer that covers most expenses, while the secondary plan covers any remaining allowable expenses not covered by the primary plan. The COB allows health plans to provide health or prescription drug coverage to individuals receiving Medicare to determine their payment responsibilities. This helps ensure that the total amount paid by all insurance plans does not exceed the total costs of the health care expenses for Medicare-covered services and items.


This article provides a general overview of COB rules under Medicare.

How Does Medicare Work With Other Insurance?

There are many important facts to remember regarding how other insurance works with Medicare-covered services and items, such as the following:


  • The primary payer pays first and up to its coverage limits.
  • The secondary payer only pays if there are costs the primary payer doesn’t cover.
  • The secondary payer, which may be Medicare in certain situations, might not pay all the uncovered costs from the primary payer.
  • If a group health plan or retiree coverage is the secondary payer, the individual may need to enroll in Medicare Part B before that insurance would pay.


If a Medicare-covered individual’s other health insurance is the primary payer and fails to promptly pay a claim, typically within 120 days, that individual’s doctor or service provider may bill Medicare. Medicare can make a conditional payment for the individual’s claim, recovering any payments the primary payer should have paid at a later date.


What’s a Conditional Payment?

A conditional payment is a payment Medicare makes for services for which another payer may be responsible. Medicare makes this payment, so the plan participant or beneficiary won’t have to pay the claim. The payment is conditional because it must be repaid to Medicare if the Medicare-covered individual receives a settlement, judgment, award or other payment later.


Who Pays First?

When an individual has Medicare and other insurance, there are rules for whether Medicare or the other insurance is the primary payer for Medicare-covered services and items. 


Medicare is typically the primary payer for Medicare-covered services and items in the following circumstances:

  • An individual is covered by only Medicare and Medicaid.
  • An individual covered by Medicare refuses group health coverage.
  • Medical services or supplies are not covered under a group health plan but are covered under Medicare.
  • A Medicare-covered individual is covered by a group health plan but has exhausted their coverage under the group health plan.
  • A Medicare-covered individual is 65 or older and covered by a group health plan (because the individual or their spouse is still working) offered by an employer with fewer than 20 employees.
  • A Medicare-covered individual is 65 or older and covered by an employer group health plan after retirement.
  • A Medicare-covered individual is 65 or older (or disabled) and covered by Medicare and the Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage.
  • A Medicare-covered individual is disabled and covered by a large group health plan offered by an employer with fewer than 100 employees.
  • A Medicare-covered individual has end-stage renal disease and is enrolled in a group health plan or COBRA (after 30 months of eligibility or entitlement to Medicare).
  • A Medicare-covered individual has only Medicare and TRICARE coverage unless the individual is on active duty and receives services and items from a military hospital, clinic or other federal health care provider.


For a complete list of situations where Medicare is the primary payer, visit Medicare.gov or review the Centers for Medicare and Medicaid Services’ guide, Medicare & Other Health Benefits: Your Guide to Who Pays First.


How Does Medicare Know if an Individual Has Other Coverage?

COB permits an individual’s Medicare eligibility information to be shared with other payers and sends Medicare-paid claims to secondary payers for payment. The Benefits Coordination and Recovery Center (BCRC) does the following on Medicare’s behalf:


  • Collect and manage information on other types of coverage an individual with Medicare may have.
  • Determine whether an individual’s other coverage pays before or after Medicare.
  • Pursue repayment when Medicare makes a conditional payment.


Medicare doesn’t automatically know if a Medicare-covered individual has other health insurance; however, insurers are required to notify Medicare when they’re responsible for paying first for Medicare-covered services and items. In some instances, the individual’s health care provider, employer or insurer may ask them about their current coverage so they can report that information to Medicare. Additionally, insurers must report coverage changes to Medicare.


Summary

Understanding COB rules is vital to ensuring that a Medicare-covered individual’s claims are paid correctly. While COB rules can be complex, they can help Medicare plan participants and beneficiaries make the best use of their health care coverage.


For more health care resources, contact SimcoHR today.

Sign up for our newsletter.

2026 Retirement Plan Contribution Limits Raised by IRS: Key Updates for 401(k) and More

November 20, 2025
The IRS recently announced the updated retirement plan contribution limits for 2026, reflecting cost-of-living adjustments and new guidance under the SECURE 2.0 Act. Whether you’re an employer managing a company plan or an employee planning for your future, these changes are important to understand so you can make the most of your retirement savings. Key Increases for 2026 Some of the most notable updates for defined contribution plans, including 401(k), 403(b), and 457(b) plans, are summarized in the chart below: 

The Employer's Guide to 2026 Minimum Wage Updates

November 5, 2025
As we move into 2026, employers across many states and localities are preparing for significant minimum wage increases. Nearly 20 states and more than 40 local jurisdictions will raise their wage thresholds effective January 1, 2026. This poses important planning, budgeting, and compliance considerations, especially for mid-sized employers like those that partner with Simco, where payroll, HR, benefits and advisory services intersect. Below we’ve summarized key state and local minimum wage updates and outlined the steps you should take now to stay ahead of the changes and mitigate risk. State-Level Minimum Wage Increases (January 1, 2026) The table below highlights selected state increases scheduled for January 1, 2026.

The Benefits of Outsourcing HR: Save Time, Cut Costs, and Boost Engagement

October 24, 2025
When HR Is Overloaded, Your Business Feels It For many small to mid-sized businesses, HR is one of the most critical (and most overextended) functions. From payroll and benefits to onboarding and compliance reporting, administrative tasks can quickly consume your team’s time, leaving little room for strategic work that actually moves the business forward. Sound familiar? You’re not alone. A recent survey from Champions of Change: isolved’s Fourth-Annual HR Leaders’ Research Study found that 51% of HR leaders spend four or more hours a day answering repetitive questions. This time could be better spent on employee engagement, culture, and growth initiatives. When HR teams are pulled in too many directions, the consequences ripple across the entire organization, resulting in missed deadlines, frustrated staff, compliance risks, and ultimately, higher turnover. Why HR Leaders Consider Outsourcing Outsourcing HR isn’t just for businesses without dedicated HR teams. In fact, a survey of 1,000 HR decision-makers found that 76% could benefit from outsourcing certain tasks, even though only 54% currently have plans to do so. HR outsourcing allows organizations to offload both core and strategic tasks, including payroll, benefits administration, recruitment, onboarding, compliance support, performance management, employee relations, and workforce analytics, without adding headcount. This augmentation provides a multiplier effect: a small HR team can function like a much larger one, accomplishing more in less time. By leveraging experienced HR professionals through outsourcing, organizations can free up internal HR teams to focus on initiatives that directly impact business growth, such as talent development, employee engagement, and culture-building. Routine administrative tasks, when handled externally, no longer distract from these high-value priorities. The True Cost of Administrative Overload Overburdened HR teams don’t just affect your internal operations; they impact your employees’ experience. Inconsistent onboarding can create a rocky first impression for new hires. Delayed payroll or benefits questions lead to frustration and decreased trust. Compliance oversights expose your business to fines and legal risk. Even small inefficiencies add up. According to the National Association of Professional Employer Organizations (NAPEO), organizations that leverage an outsourced HR model achieve an average ROI of 27.2% per year, saving around $1,775 per employee while paying $1,395 per employee for outsourced services. That’s not just cost savings, it’s a reinvestment in your team and your business. The Power of Strategic HR Outsourcing Outsourcing doesn’t mean giving up control or handing HR off to a faceless provider. Done strategically, it’s about extending your team. Administrative tasks like payroll, benefits, onboarding, and reporting can be handled efficiently by experts, while HR teams gain confidence that compliance requirements are being met. Most importantly, it frees internal HR to pivot from reactive, day-to-day tasks toward engagement, culture-building, and retention strategies. Outsourced HR support can scale with your business, providing additional expertise during busy periods, leaves of absence, or rapid growth phases. The impact is clear. Teams feel supported, employees feel heard, and the organization operates smarter, not harder. With the right outsourcing partner, a small HR team can act like a team of 10, and a team of five can perform like a team of 25, all while maintaining compliance and efficiency. Retention Starts With the Right Employee Experience When administrative burdens are reduced, HR teams can focus on creating meaningful experiences for employees. Transparent processes around pay, benefits, and policies build trust. Faster, more organized onboarding leaves a strong first impression. Access to modern self-service HCM tools empowers employees to manage their own information, reducing repetitive questions and improving engagement. By leveraging experienced HR professionals to handle gaps in internal processes, organizations can enhance overall employee satisfaction, ensuring every interaction, from onboarding to open enrollment, feels seamless and supportive. A Smarter Approach to HR Means a Stronger Business Across industries, companies are recognizing that HR outsourcing is no longer a luxury. It’s a strategic advantage. Organizations that adopt a blended model of technology and advisory support report measurable reductions in administrative workload, cost savings compared to maintaining fully in-house HR teams, and improved engagement for employees. Strategic HR outsourcing allows internal teams to shift from transactional tasks to big-picture initiatives, creating a more resilient, efficient, and high-performing workforce. At the end of the day, HR isn’t just a function; it’s the backbone of your organization. When it’s overextended, the entire business suffers. But with the right support, HR teams can focus on meaningful initiatives, employees feel more valued, and the business benefits from measurable ROI. Strategic HR outsourcing isn’t about replacing your team, it’s about empowering it. Your people, your culture, and your bottom line all benefit. Curious how Simco's HR Advisory services can help your business? Let's talk today.

Have a question? Get in touch.