A Primer for Employers on Medicare Coordination of Benefits
October 23, 2023
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 Simco today.

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The Hidden Costs of Fragmented Workforce Management Vendors

September 2, 2025
Many businesses rely on multiple vendors to manage critical functions such as HR, payroll/HCM, benefits, commercial insurance, and retirement plans. While outsourcing can provide specialized expertise in each area, using separate providers often creates hidden costs that can quietly undermine efficiency, accuracy, and employee satisfaction. Here’s why integration matters, and how a consolidated approach can save time, reduce risk, and improve the employee experience. 1. Increased Administrative Burden When each service is managed by a separate vendor, administrative work multiplies. Employees and HR teams may spend extra hours logging into different systems to process payroll, submit benefits updates, or manage compliance tasks. Reconciling employee information across multiple portals and coordinating communications between vendors creates unnecessary complexity, which can distract your team from strategic priorities. 2. Higher Risk of Errors and Compliance Issues Fragmentation can increase the likelihood of costly mistakes. Payroll errors, mismanaged retirement contributions, and insurance coverage gaps often occur when systems do not communicate effectively. A single misalignment can have a ripple effect: Incorrect payroll deductions Late or missing retirement contributions Gaps in insurance coverage or compliance violations With multiple vendors, the risk of these errors and their consequences rises. 3. Limited Visibility and Reporting When each service lives in its own system, it’s hard to get a complete picture of your workforce. Without centralized reporting, many businesses struggle to: Analyze labor costs or benefits spending accurately Identify compliance gaps or coverage issues Track trends in employee engagement and retention Limited visibility makes it difficult to make informed decisions and optimize operations. 4. Compounded Costs Paying multiple vendors for separate services often results in more than just the sum of their fees. Each system typically comes with its own implementation, training, and subscription costs, which can quickly add up. In addition, internal administrative hours spent managing vendor relationships, reconciling conflicting data, or troubleshooting errors create a hidden expense that is often overlooked. Businesses may also face unexpected costs when trying to integrate or transfer data between disconnected platforms, or when compliance issues arise due to misaligned processes. Over time, these scattered costs compound, reducing overall efficiency and limiting resources that could be better spent on strategic growth initiatives. 5. Frustrated Employees The impact of fragmentation extends to employees. They may face confusion about where to access benefits or payroll information, experience delays in issue resolution, or encounter inconsistent communications. This frustration can lead to disengagement, lower productivity, and higher turnover. Businesses that integrate these functions provide a smoother, more cohesive experience for employees, resulting in higher satisfaction, better engagement, and a stronger workplace culture. Why Integration Matters Integrating HR, payroll/HCM, benefits, commercial insurance, and retirement services with a single partner simplifies operations, reduces errors, improves reporting, and enhances the employee experience. Businesses that consolidate services gain: Streamlined administrative processes and reduced duplication of effort Improved accuracy and compliance through connected systems Enhanced visibility into workforce metrics and financials Cost efficiencies by eliminating overlapping fees and redundant systems A more consistent, positive experience for employees By managing these services in a unified platform, your business can focus on growth instead of juggling multiple systems and vendors. Take the Next Step If your business is managing multiple vendors for HR, payroll, benefits, insurance, and retirement, it’s time to consider a more integrated approach. Streamlining these services with a single, high-touch partner like Simco can save time, reduce risk, and create a better experience for both your team and your employees.

Strategies for Supporting Employees During the School Year

August 25, 2025
As the 2025–26 school year gets underway, many employees are navigating the dual pressures of professional responsibilities and family life. For parents of school-aged children, this can mean adjusting to new routines, handling childcare logistics, and managing the emotional ups and downs that often accompany the start of the year. For employers, this season offers an opportunity to demonstrate support and strengthen employee loyalty. Below are nine strategies businesses can adopt to help their workforce balance work and family demands more effectively. Flexible Work Options Flexibility remains one of the most powerful ways to support working parents. Allowing employees to shift their schedules, such as starting earlier or later, or offering hybrid and remote work options helps parents handle school drop-offs, pickups, and unexpected schedule changes. For example, permitting an employee to work from home two mornings a week may relieve the stress of managing transportation while ensuring business needs are still met. When employees feel trusted to manage both work and family responsibilities, engagement and productivity rise. Back-to-School Support The transition into a new school year often involves extra expenses and planning. Employers can ease this burden by organizing back-to-school supply drives, offering stipends for educational expenses, or sharing curated lists of local resources like tutoring programs or after-school care. Some businesses even host “lunch and learn” sessions on topics such as family budgeting or time management during the school year. These gestures show employees that the company understands their life outside of work and wants to help them succeed in both areas. Prioritize Mental Well-Being Back-to-school season can be stressful for the whole family, with shifting routines, homework expectations, and social adjustments. Employers can proactively support mental health by promoting counseling services, stress management programs, or mindfulness workshops. Offering access to telehealth therapy sessions or creating quiet spaces in the office for breaks can make a tangible difference. Focusing on mental well-being helps employees feel cared for and creates a healthier, more resilient workforce overall. Paid Time Off for School Activities Balancing school commitments with work obligations can be difficult without supportive policies. By providing paid time off specifically for school-related events, such as parent-teacher conferences, school plays, or volunteering opportunities, employers can reduce the guilt or anxiety parents may feel about taking time away from work. Even a few hours of school-activity leave per semester can significantly boost morale and demonstrate the company’s commitment to work-life balance. Childcare Assistance Childcare remains one of the greatest stressors for working parents. Businesses can step in by offering childcare subsidies, backup childcare arrangements for emergencies, or partnerships with local providers to secure discounted rates. Employers with larger workforces may explore on-site childcare facilities or after-school program collaborations. Even simply sharing information about community resources and vetted childcare options can make a big difference for employees struggling to find reliable solutions. Open Communication Encouraging honest, ongoing conversations between managers and employees is essential. Managers should be trained to ask about potential school-year challenges, such as altered availability during drop-off hours or the need to leave for school events, without judgment. Creating a culture where employees feel safe discussing these needs allows managers to find practical solutions, like shifting deadlines or redistributing workloads, that benefit both the employee and the organization. Employee Assistance Programs (EAPs) EAPs are often underutilized, yet they can be invaluable during the school year. These programs typically offer access to counseling, parenting support, financial planning, and more. Employers should not only remind employees that these resources exist but also explain how they can be used during this time of year. For example, highlighting financial counseling services in September, when school-related expenses spike, makes the EAP more relevant and accessible. Family-Friendly Policies Workplace policies should reflect the realities of family life. Review scheduling practices to avoid early morning or late afternoon meetings when parents are often unavailable. Consider policies that allow parents to swap shifts or trade hours with coworkers. Involving employees in creating or revising family-friendly policies ensures the solutions are practical, widely supported, and foster an inclusive culture that values everyone’s needs. Recognition Matters Acknowledging the extra effort parents put in during the school year can have a lasting impact. Recognition doesn’t have to be large-scale, a personal thank-you note, a shout-out during a team meeting, or a small gift card can go a long way toward showing appreciation. Celebrating milestones, like surviving the first week back to school, helps parents feel seen and valued, reinforcing their commitment to the company. The Bottom Line Supporting employees during the school year goes beyond providing benefits; it’s about creating an empathetic, flexible, and responsive workplace culture. By adopting these strategies, businesses not only help their employees manage family responsibilities with confidence but also foster a more engaged, loyal, and productive workforce.
Is Your Business Ready for New York’s Secure Choice Savings Program (SCSP)?

Is Your Business Ready for New York’s Secure Choice Savings Program (SCSP)?

August 22, 2025
Big changes are on the horizon for New York businesses. Soon, many employers will be required to provide retirement savings options through the state’s Secure Choice Savings Program. If your business doesn’t already offer a retirement plan, now is the time to understand the rules, prepare your payroll, and explore whet

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