A Primer for Employers on Medicare Coordination of Benefits
March 24, 2023
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.
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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.
If you recently received notice that your Medicare plan, or Medicare Advantage plan, is being discontinued, you’re not alone. Across the country (and right here in New York), insurers are scaling back or exiting less profitable markets ( Kiplinger ). While this can feel stressful, there are steps you can take to make sure your coverage doesn’t lapse and to find a better plan for your health and budget. Why Are Plans Being Discontinued? A mix of financial pressure, federal reimbursement changes, and rising health costs is driving insurers to reduce their Medicare Advantage footprints: Some major insurers are cutting back or exiting entire counties. For example, UnitedHealth announced it will discontinue its Medicare Advantage presence in 109 U.S. counties in 2026, according to Reuters . Local carriers in New York are also making changes: MVP is dropping several plans, and CDPHP is eliminating certain drug-coverage options, the Times Union explains . These shifts are happening alongside tighter government funding and increased regulatory strain. Because insurers must absorb the extra cost of covering benefits while meeting regulatory caps (for example, on prescription drug out-of-pocket limits), some plans become financially unsustainable and are discontinued ( the Kaiser Family Foundation ). Steps to Take if Your Plan Is Discontinued Here’s how to act so you don’t lose coverage: 1. Review the notice you received carefully Your insurer is required to send you a non-renewal or discontinuance notice. It often includes deadlines, whether you can enroll through a Special Enrollment Period (SEP), and what options you have. 2. Note the relevant enrollment period The Annual Enrollment Period (AEP) runs October 15 to December 7, 2025 , during which you can switch Medicare Advantage or Part D plans. If your plan was discontinued, some notices allow you to select a new plan until December 31 without penalty. In limited cases, you may qualify for a Special Enrollment Period (SEP) following the discontinuation. 3. Research your options early Don’t wait until the last minute. Compare plans available in your area. Key things to look at: Provider networks: Will your doctors still be covered? Drug formularies: Does the plan cover your medications and at what cost? Premiums, deductibles, and out-of-pocket max: These can vary significantly. Benefit trade-offs: Some plans reduce supplemental benefits (vision, dental, wellness perks) when trying to maintain financial viability. 4. Enroll in the new plan Submit your enrollment by the relevant deadline (typically December 7 for the Annual Enrollment Period (AEP). However, If your plan was discontinued, you may have until December 31 to choose a new one without penalty). Make sure the new plan starts January 1 to avoid coverage gaps. 5. If your plan wasn’t discontinued, still review Even if your current plan remains active, benefits, networks, and costs often change each year. It’s wise to compare alternatives anyway, especially after insurer shake-ups. Why Timing & Support Matter Delays cost you: Failing to enroll by deadlines could mean losing drug coverage or being locked into a less ideal plan. Support can ease the burden: Licensed agents can help you compare side-by-side, explain trade-offs, and guide you through enrollment. You deserve the best match: Everyone’s health and financial needs differ. Don’t settle for the first available option unless it truly fits. How Simco Can Help At Simco, we understand the stress of sudden plan changes. Our licensed insurance advisors are ready to: Help you interpret your discontinuance notice Compare plan options available in your area Assist with enrollment paperwork Explain benefit trade-offs and cost implications You don’t have to navigate this alone. Whether your Medicare Advantage plan was discontinued or you’re simply exploring your options, our team is here to support you. Contact us today to schedule a 1-on-1 consultation, and let us help you find the plan that keeps you covered and confident in 2026 and beyond.
At Simco, we’re proud to be a trusted isolved Network Partner , which means the Human Capital Management (HCM) technology we deliver to our clients is powered by isolved People Cloud™. And now there’s even more reason to celebrate: isolved has been recognized as the #1 SMB HCM provider across the entire employee lifecycle in Sapient Insights Group’s 28th Annual HR Systems Survey. This annual survey is one of the most respected benchmarks in the HR technology industry. With feedback from over 4,500 HR professionals, Sapient Insights captures the real voice of the customer by evaluating vendors across two critical areas: User Experience (UX) and Vendor Satisfaction (VS). isolved earned an impressive 38 badges this year, the most awarded SMB vendor for the second year in a row, and ranked #1 in 13 different SMB categories . Breaking Down the Results isolved’s recognition wasn’t limited to a single function. It spanned the entire employee lifecycle, covering everything from payroll and benefits to recruiting and workforce management. Highlights from the survey include: Payroll — Ranked #1 in both User Experience and Vendor Satisfaction for SMBs Core HR — #1 in Vendor Satisfaction Benefits — #1 in User Experience Recruiting — #1 in both User Experience and Vendor Satisfaction Time & Attendance — #1 in both User Experience and Vendor Satisfaction Skills Management — #1 in User Experience Rewards & Recognition — #1 in User Experience In addition, isolved placed in the Top 5 across numerous other categories like onboarding, learning, performance management, workforce scheduling, and contingent management. What does this mean? isolved’s solution isn’t just strong in one area, it’s consistently delivering across all the areas that matter most for small and mid-sized businesses. Why This Matters for SMBs Today’s SMBs face more challenges than ever. Recruiting is competitive, employee expectations are higher, and compliance requirements grow more complex every year. Business owners often find themselves piecing together multiple vendors to handle payroll, HR, benefits, and insurance, adding complexity and risk. isolved’s sweep across the Sapient Insights report shows that SMBs no longer have to choose between great payroll software and effective talent tools, or between benefits management and workforce scheduling. With isolved, the technology already covers the full employee lifecycle, validated by real-world HR pros. From Recognition to Results isolved’s 38 badges and top rankings validate what our clients experience every day: Accuracy and trust in payroll with fewer errors and compliance risks. Simplified benefits administration that keeps employees happy and businesses competitive. Recruiting and onboarding tools that make hiring more effective. Time and scheduling solutions that align workforce needs with operational efficiency. These results aren’t just about technology; they’re about enabling SMBs to compete, thrive, and support their people better. The Simco Advantage: More Than Just Software Here’s the ultimate key: technology is only half of the solution. Technology is powerful, but the real impact comes from how it’s put into practice. At Simco, we go beyond simply providing software. We deliver a fully integrated HCM and advisory solution that ties every part of workforce management together. Here’s what sets us apart: One Point of Contact: A dedicated resource who understands your business and ensures your HCM, HR, benefits, insurance, and retirement services work in sync. All-in-One Partner: From payroll and HR to insurance and 401(k) plans, we eliminate the hassle of juggling multiple vendors. Advisory + Optimization: We don’t just implement technology. We guide you in using it to strengthen compliance, employee engagement, and growth strategies. As your business grows, your needs change. By pairing isolved’s award-winning technology with Simco’s hands-on expertise, we help you stay ahead, operate more efficiently, and build better employee experiences. Key Takeaways isolved’s recognition in the Sapient Insights report shows that SMBs have access to enterprise-grade HR technology tailored for their needs. And with Simco as your partner, you’ll never have to choose between the strength of your platform and the quality of your service; you’ll have both. Want to see how Simco + isolved can streamline your payroll, HR, benefits, and more? Contact us today.
