A Primer for Employers on Medicare Coordination of Benefits
October 23, 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 Simco today.
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The Fourth of July is almost here, and communities across Ontario County are gearing up for a weekend filled with parades, fireworks, and hometown celebrations. Whether you're heading out for live music and lawn games or simply enjoying time with friends and family, there are plenty of ways to celebrate locally. At Simco, we’re proud to support our neighbors with practical tips to enjoy the holiday safely, while making sure your insurance coverage is up to date and ready for the unexpected. Where to Watch Fireworks in Ontario County JULY 3 Farmington – Fireworks at dusk with food trucks and live music starting at 6 PM (Farmington Town Park) Honeoye Lake – The beloved “Ring of Fire” lights up the lake, with parking available at Sandy Bottom Park JULY 4 Canandaigua – Lincoln Hill Farms hosts an all-day celebration (1–10 PM) with fireworks after dark, music, games, and more. ($30 parking, cash only) JULY 5 Canandaigua North Shore – Keep the celebrations going with another round of fireworks at dark JULY 11 Geneva – Free Summerfest fireworks at 9:45 PM at the Geneva Recreation Center Parade Lineup JULY 3 Honeoye – Parade at 7 PM from United Church to Sandy Bottom Park. Stick around for the Honeoye Community Band and the Ring of Fire afterward! JULY 4 Canandaigua – The city’s annual 4th of July Parade kicks off at 10 AM from City Hall and heads south along Main Street JULY 12 Geneva – Firefighters Parade begins at 7 PM on Exchange Street, ending at the Geneva Rec Center for SummerFest festivities What Fireworks Are Legal in New York? While fireworks are a staple of July 4th, not everything that sparks and explodes is legal in New York State. Using illegal fireworks can actually void your insurance coverage if something goes wrong. What’s Allowed in NY: Ground-based or handheld sparkling devices (like cylindrical fountains or cones) Wooden sparklers/dipped sticks Party poppers Snappers (the small “pop” ones) What’s Not Allowed (and Not Covered): Aerial consumer fireworks Firecrackers Chasers Roman candles Skyrockets Bombs (even small ones!) Metal wire sparklers (they burn much hotter than they look) Quick Tip: If it launches into the sky or explodes, it’s not legal. Stick to sparklers and save yourself a potential insurance headache. Insurance Tips for a Safe Holiday A little awareness goes a long way in protecting your home, family, and peace of mind this 4th of July. Stay within NY guidelines. If an incident is caused by illegal fireworks, your insurer may deny the claim. Keep safety front and center. Supervise all activities involving sparklers or devices and keep water nearby for emergencies. Know what your policy covers. Not every homeowner’s policy includes damage from fireworks-related accidents. If you’re unsure, reach out. We’re happy to review your coverage. Report incidents quickly. Prompt reporting helps ensure claims are handled smoothly and effectively. From All of Us at Simco We’re wishing you a joyful, memorable, and safe Independence Day. Whether you’re lighting up the sky with sparklers or relaxing lakeside with family, we’re here to help you protect what matters most, before, during, and after the festivities. Have questions about your insurance coverage this summer? 📞 Call us at 585-394-5482 or visit our Contact Us page.
As organizations continue to grow and diversify, the way we communicate at work is evolving, bringing new opportunities for inclusion as well as potential blind spots. One issue that often goes overlooked is accent discrimination: the tendency to judge, exclude, or undervalue individuals based on their speech patterns, dialect, or pronunciation. While accents are often rooted in geography, heritage, or culture, bias toward or against certain ways of speaking can influence decisions in hiring, promotions, evaluations, and daily interactions. For employers, particularly those in small to mid-sized organizations, understanding where this shows up and how to respond isn’t just about creating a respectful workplace. It’s also essential for risk mitigation and legal compliance. What Constitutes Accent Discrimination? Accent discrimination occurs when employees or candidates are treated unfairly due to the way they speak. This type of treatment may stem from overt, conscious bias, such as assuming someone is less capable based on how they sound, or from more subtle, unconscious preferences, like favoring those who speak in what’s perceived as a “standard” or “neutral” accent. Legally, accent-based discrimination can be considered a form of national origin discrimination, which is prohibited under Title VII of the Civil Rights Act. Many states reinforce these protections through their own civil rights laws. Employers should be aware that even unintentional practices, such as informal communication preferences or subjective feedback, can result in compliance issues or reputational damage. Clear Communication vs. Discriminatory Practice It is important to distinguish between legitimate communication needs and bias. In certain narrowly defined circumstances, an accent may be relevant to an employee’s ability to perform essential duties. For instance, in roles that require precise, real-time verbal communication, such as emergency response or high-risk operational jobs, an employer may need to assess whether a language barrier or speech pattern materially interferes with safety or accuracy. However, such evaluations must be backed by objective evidence and a clearly defined business necessity. Vague discomfort, personal preference, or client feedback based on unfamiliarity are not valid reasons to deny someone an opportunity. Any decision related to an accent must be both job-related and supported by measurable performance impacts. Standardize Hiring and Promotion Processes to Minimize Bias One of the most effective ways to reduce the risk of discrimination is by formalizing your hiring and promotion practices. Employers should examine whether their processes allow room for bias (conscious or unconscious) to influence decisions. Subjective impressions, especially in interviews or internal evaluations, can be disproportionately shaped by how a person speaks. To counteract this, companies should move toward structured, competency-based hiring frameworks. Use consistent criteria and scoring systems across all candidates, and rely on written assessments or role-specific tasks where appropriate. Similarly, promotions should be guided by documented performance metrics, not informal perceptions of professionalism or communication style. In doing so, not only do you reduce the chance for bias to affect outcomes, but you also make better staffing decisions that reflect skills, qualifications, and organizational fit: not speech patterns. Why This Matters More Now In today’s hybrid and remote work environments, the ability to navigate diverse communication styles has become even more important. With teams collaborating across geographic regions and cultural backgrounds, inclusivity in communication is essential for morale, cohesion, and productivity. Moreover, younger workers and job seekers are placing a high value on belonging and inclusion. Discriminatory or exclusionary behavior, intentional or not, can quickly erode trust and lead to disengagement or turnover, especially when tied to identity-based characteristics like accent or dialect. Employers who lead with fairness in communication are more likely to attract and retain talent, maintain strong teams, and avoid costly compliance missteps. Building a Culture Where All Voices Are Valued Ultimately, embracing different accents in the workplace is about genuine, judgment-free listening. Employers should encourage active listening practices, create space for respectful clarification when needed, and ensure employees feel safe speaking up, regardless of how they sound. Miscommunication is a solvable issue. Discrimination is not. Leaders who prioritize clarity, fairness, and consistency, rather than conformity, build workplaces that are both inclusive and high-performing. And the benefits go beyond compliance. They create environments where people thrive because they are heard and valued.
With summer travel in full swing and Labor Day just around the corner, expect a surge in time-off requests, and for good reason. Employees need time to recharge, spend time with family, and enjoy the season. For employers, especially in small to mid-sized businesses, this means finding the delicate balance between fostering a supportive work culture that respects employees’ need for time away and managing the practical realities of maintaining adequate coverage, meeting deadlines, and keeping operations running smoothly. The good news? With thoughtful planning, clear communication, and the right tools in place, you can navigate this busy season effectively, ensuring your team gets the rest they deserve without compromising business continuity. Here are a few practical strategies to help you manage PTO during the summer months while keeping your business running smoothly: 1. Plan Early and Communicate Clearly Encourage employees to submit holiday PTO requests well in advance. Set a clear internal deadline (e.g., “All holiday time-off requests must be submitted by August 15”) and explain the process upfront, including: How requests will be reviewed and approved How overlapping requests will be handled Any blackout dates or essential coverage periods A clear and consistent approach eliminates guesswork, reduces friction, and helps everyone feel they’re being treated fairly. 2. Use a PTO Policy That Balances Fairness and Flexibility Your time-off policy should include guidelines for high-demand periods like Thanksgiving, Christmas, and New Year’s. Some companies use: First-come, first-served approvals A rotation system so everyone eventually gets prime time off A seniority or department-based system with built-in equity checks Whatever method you choose, consistency is key. A well-documented policy gives managers a framework to follow, and gives employees peace of mind that decisions are made justly, not arbitrarily. 3. Leverage Your HCM or Scheduling Technology If you're using a system like isolved , you already have powerful tools to streamline the PTO process. Automate request tracking, visualize department coverage in real time, and flag conflicts early to avoid blind spots. This gives HR and team leads the visibility they need to make smart, timely decisions. Bonus tip: Use system alerts to notify managers when coverage is thin, or configure it to close PTO windows automatically after a set date. These features take manual work off your plate while protecting productivity. 4. Cross-Train and Create Holiday Coverage Plans Rather than scrambling when someone’s out, prepare your team to adapt. Cross-train employees in advance so they can cover essential tasks if a teammate is unavailable. Before the busy season kicks in, put together a simple holiday coverage plan that outlines: Who will monitor essential tasks (client inquiries, payroll processing, etc.) What needs to get done and by whom each week Who’s available for backup support if needed A little upfront planning makes a big difference in keeping service levels steady during staff absences. 5. Appreciate Those Who Step Up Don’t let holiday contributions go unnoticed. Employees who work through the holidays or shift their schedules to ensure coverage deserve meaningful recognition. Consider: Spot bonuses or incentives Public recognition in a team meeting or internal email Additional time off (comp time) after the holidays Even small gestures show your team that their flexibility and dedication are valued, and that you see the extra effort. 6. Set Expectations With Clients (and With Your Team) If your operations will run on limited hours or staffing during the holidays, notify clients and partners well in advance. Clear communication avoids surprises and sets realistic expectations. Internally, define what’s essential versus what can wait, especially to avoid employees overworking during slower periods. When everyone understands what’s expected, your team can better prioritize, delegate, and breathe a little easier during the season. Final Thought: Flexibility Builds Loyalty The holiday season is a test of your workplace culture. How you support your team, especially when juggling competing needs, leaves a lasting impression. Even when saying no to a request, doing so with empathy and transparency reinforces a culture of trust, fairness, and respect. And in return, you'll see greater engagement, improved morale, and a team that’s ready to go the extra mile — during the holidays and beyond. Need help building better time-off workflows or updating your PTO policies before year-end? Simco’s HR and HCM experts are here to help. Let’s talk about how to balance compliance, efficiency, and employee satisfaction, all year round.
