Jeffrey P. Gale, P.A. // Medicare-Eligible Individuals With Group Health Insurance Beware!

In our practice—focused on personal injury, medical negligence, workers’ compensation, and wrongful death—we routinely handle Medicare and health insurance liens. These entities often have statutory or contractual rights to be reimbursed from any settlement or judgment recovered from third parties, meaning those legally responsible for causing the harm.

This article addresses a separate legal issue involving medical expenses.

When individuals turn 65, they become eligible for Medicare. It’s not uncommon for those with private group health insurance to mistakenly believe they don’t need to enroll in Medicare at that time.

That assumption is generally accurate if the individual or their spouse is actively employed by a company with 20 or more employees. In such cases, the employer-sponsored group health plan is considered the primary payer, and Medicare functions as secondary coverage. These individuals remain covered even if they delay enrolling in Medicare, as long as the employer-sponsored group health plan is primary.

Problems arise when Medicare-eligible individuals have employer coverage through a company with fewer than 20 employees and fail to enroll in Medicare. In these situations, Medicare is considered the primary payer, and the employer plan may refuse to cover claims that Medicare should have paid. Moreover, if the group health insurer initially pays a claim it wasn’t responsible for—because Medicare should have been primary—it may seek to recover that payment from the medical providers. In turn, those providers often pursue the patient directly for the unpaid balance.

Similarly, if an individual is over 65 and has retiree health coverage or continues employer-sponsored insurance through COBRA (the Consolidated Omnibus Budget Reconciliation Act), Medicare is considered the primary payer. The secondary coverage will only pay if Medicare has paid its portion first. Furthermore, if the secondary insurer mistakenly pays for services that Medicare should have covered, it has the right to recover—or “claw back”—those funds, potentially from the provider or the patient.

There are no clear obligations for insurers, employers, or the government to inform individuals about how coordination-of-benefits rules may change once they become eligible for Medicare.

One potential remedy for individuals facing this dilemma is to pursue legal action against the broker responsible for managing the employer’s health insurance plan for failing to provide adequate information. This option is less than ideal.

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Contact us at 305-758-4900 or by email to learn your legal rights.

Jeffrey P. Gale, P.A. is a South Florida based law firm committed to the judicial system and to representing and obtaining justice for individuals – the poor, the injured, the forgotten, the voiceless, the defenseless and the damned, and to protecting the rights of such people from corporate and government oppression. We do not represent government, corporations or large business interests.

While prompt resolution of your legal matter is our goal, our approach is fundamentally different. Our clients are “people” and not “cases” or “files.” We take the time to build a relationship with our clients, realizing that only through meaningful interaction can we best serve their needs. In this manner, we have been able to best help those requiring legal representation.

DISCLAIMER: This information provided by Jeffrey P. Gale, P.A. is for informational purposes only and is intended to be used as a non-legal guide prior to consultation with an attorney familiar with your specific legal situation. It should not be considered legal advice or counseling. No such legal advice or counseling is either expressly or impliedly intended. This information is not a substitute for the advice or counsel of an attorney. If you require legal advice, you should seek the services of an attorney.