Category: Medicare

Things change if you are on Medicare due to a disability rather than age. The government gives larger employers more responsibility here.

• Large Group Health Plan (100+ Employees): If the employer has 100 or more employees, the employer plan pays Primary.
• Smaller Groups (Under 100 Employees): Medicare pays Primary.

This is a common "gotcha" for businesses with 50 or 75 employees. They are used to being "Primary" for their 65+ workers, but for a disabled employee on Medicare, the roles flip! (It’s enough to give anyone a headache, which is why we’re here to help.)

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4. How Do You Count "Employees" Anyway?

You’d think counting to 20 or 100 would be easy. But the IRS and Medicare have their own way of doing math. Here are the rules that usually surprise business owners:

• Full-time vs. Part-time: They both count. If you have 10 full-timers and 15 part-timers who only work 10 hours a week, you have 25 employees in Medicare's eyes. (You have met the 20-employee threshold.)
• The "20-Week" Rule: You don't have to have 20 employees every single day. If you had 20 or more employees for at least 20 weeks in either the current or the preceding calendar year, you are considered a "20+ employer" for the entire year.
• Controlled Groups: If you own three separate LLCs with 7 employees each, Medicare sees you as one employer with 21 employees. You can’t hide from the MSP rules by splitting your staff across different companies.
• Worldwide Count: If you work for a small branch of a massive international corporation, Medicare counts the total number of employees worldwide. That "small" local office is actually a "Large Group."

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5. The Special Cases: ESRD, COBRA, and Retirees

Just when you think you've got it, Medicare throws a curveball. (I like to call these the "Expert Level" rules.)

End-Stage Renal Disease (ESRD)

If you have ESRD, your employer plan is Primary for the first 30 months of your Medicare eligibility, regardless of how many employees the company has. After that 30-month "coordination period," Medicare becomes Primary.

COBRA (The Big Trap)

This is the one that keeps me up at night. If you leave your job and take COBRA, Medicare is almost always Primary.

If you are 65+ and on COBRA, and you don't sign up for Medicare Part B, COBRA might pay $0 on your hospital bill, assuming Medicare should have paid first. We’ve seen retirees lose their life savings because they didn't realize COBRA doesn't count as "active employment" coverage. (Seriously, if you are considering COBRA and you're 65, call us first.)

Retiree Coverage

Like COBRA, retiree health insurance is Secondary to Medicare. If you have a retiree plan, you generally need Medicare Parts A and B to have full coverage.

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6. Why "Never Accepting No" Matters

Navigating these rules is like walking through a minefield. One wrong step, like missing a Part B enrollment window because you miscounted your employees, can lead to lifetime late enrollment penalties. (That’s a permanent 10% increase on your premium for every year you waited!)

At Total Benefit Solutions Inc., we don't just hand you a brochure and wish you luck. We act as your advocates.

• We shop the market to see if an individual Medicare plan is actually cheaper and better than your employer plan (often it is!).
• We help HR managers count their employees correctly so they don't violate federal MSP laws.
• We fight the insurance companies when they try to "Secondary" a claim that should have been "Primary."

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7. Action Steps for You

If you are approaching 65 or managing a team, here is your Medicare coordination checklist:

1. Do an Employee Audit: Count every head on your payroll (including part-time and seasonal). Are you over or under 20?
2. Check Your Payer Status: If you’re a small group (under 20), make sure your 65+ employees know they likely need to enroll in Medicare Part B to avoid coverage gaps.
3. Review COBRA Early: If an employee is over 65 and leaving the company, don't just offer them COBRA. Help them understand how it interacts with Medicare.
4. Ask an Expert: You don't have to be a lawyer to understand these rules, you just have to know one (or a very dedicated insurance broker).

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We’re Here to Fight for Your Benefits

Medicare Secondary Payer rules aren't just red tape; they are the framework that determines your financial security in retirement. Whether you’re an individual trying to decide when to enroll, or a business owner trying to stay compliant, we’ve got your back.

At Total Benefit Solutions Inc., we specialize in health insurance advocacy. We help you navigate the rules, find the best grants and programs, and we never accept "no" as an answer when it comes to your rights.

Want a free review of your Medicare or Employer Group status?

Visit us at www.totalbenefits.net or give us a call at (215) 355-2121. Let’s make sure you’re protected!

#InsuranceAdvocacy #MedicareTips #NeverAcceptNo #SmallBusinessOwner #HealthInsuranceExpert

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Disclaimer: The information provided in this blog is for educational purposes and does not constitute legal or tax advice. Medicare rules can change (and they often do!), so always consult with a licensed professional regarding your specific situation.

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