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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It’s April 15—Tax Day in the U.S.—and if you’re a business owner or HR professional, chances are W-2s, filings, and compliance have been front and center for weeks (if not months). But here’s the thing: tax season doesn’t have to be stressful. The right payroll and HCM technology can turn what’s traditionally a time-consuming, error-prone scramble into a streamlined, accurate, and surprisingly painless process. From automatically balancing year-to-date totals to generating and distributing W-2s on time, a robust payroll system ensures nothing slips through the cracks. No more cross-checking data across platforms, no more last-minute tax filings, and no more anxiety about penalties or missed deadlines. At Simco, we get it—because we help businesses simplify this process every single day. The Challenges of Traditional Payroll Tax Management If you're still managing payroll taxes manually—or using disconnected software systems—it’s all too easy to fall behind. Some common issues employers face include: Human error : Tax calculations, forms, and deadlines are complex. A small mistake can lead to penalties or costly overpayments. Time-consuming manual work : Without automation, payroll processing can involve endless imports, exports, and reconciling data across multiple platforms. Compliance risk : With ever-changing tax laws at the federal, state, and local levels, staying compliant can become overwhelming without the right tools. How the Right Technology Can Make Tax Season a Breeze Today’s modern payroll and HCM systems are designed to simplify these challenges. Here’s how the right technology can help: 1. Automated Tax Filing and Payments: An integrated payroll system automates tax calculations, deductions, and filings. Forms like W-2s and W-3s are automatically generated, filed, and paid—without manual input. This reduces the risk of late filings, penalties, and missed deadlines, ensuring compliance with the IRS and state tax agencies. 2. Streamlined W-2 Management: W-2s can be a headache to manage—especially if you have complex tax scenarios like multi-state employment. With an automated system, W-2s are generated and distributed electronically, ensuring accuracy even in complex situations. Employees receive the correct form without you having to spend valuable time cross-checking or manually making corrections. 3. Self-Balancing Capabilities: A self-balancing payroll system ensures that your year-to-date totals and tax filings are accurate, eliminating the need for extensive manual reconciliation. By automatically matching figures in real-time, it streamlines year-end reporting, providing peace of mind when the filing deadline approaches. 4. Fewer Third-Party Imports and Exports: With everything integrated into a single platform, you won’t need to rely on third-party software or services for tax filing and reporting. This means fewer opportunities for errors, fewer manual imports and exports, and significant time saved during payroll processing. 5. Automated Adjustments and Updates: Tax laws and rates change frequently. With the right payroll system, you won’t have to worry about manually updating deductions or tax rates. The system automatically applies changes—whether it’s an update to federal tax rates or state-specific deductions—so your payroll is always up to date. 6. Expert Support When You Need It: Even with the best technology, tax season can present complex challenges. That’s why it’s important to have access to expert support. Whether you need help with multi-jurisdiction filings, audit preparation, or just have questions about tax return procedures, our team of HCM Specialists at Simco is here to provide guidance and ensure that you’re compliant every step of the way. Why Choose Simco for Smarter Payroll and Tax Management? As an isolved Network Partner, we offer a fully integrated payroll and tax management system that is built to handle the complexities of tax season—and beyond. We provide businesses with the tools they need to automate tax filings, ensure compliance, and streamline payroll processing. Here's how we do it: All-in-One Payroll & Tax Platform : From payroll processing to tax deposits and W-2 filings, everything happens within one system, reducing manual work and the risk of errors. Automatic Filing & Timely Accuracy : Federal, state, and local tax filings are completed automatically and on time, ensuring your employees receive only one accurate W-2 form—even in multi-state tax scenarios. Error-Free Tax Reporting : Our self-balancing ledger helps reduce errors and simplifies reconciliation, making tax reporting easier and faster. Expert Support : Whether it’s navigating multi-jurisdictional filings, preparing for an audit, or handling amendments, our team is always available to offer expert advice and assistance. Cost-Effective Solutions : We offer top-tier tech at competitive pricing, often matching or beating our competitors (learn about the Simco Price Match Commitment here !), while providing the personalized service that large providers can’t. Let’s Make Next Tax Season Easier, Starting Today It’s never too early to think about next year. With our unified payroll/HCM solution at Simco, you can save time, reduce stress, and ensure compliance all year long. It’s time to upgrade your payroll system to one that works smarter, not harder. Let’s chat and explore how we can help streamline your payroll and tax processes, so you can focus on growing your business with confidence.
New month, fresh start! But let’s be real—how many times have you set a goal, only to watch it fizzle out? Maybe it was too vague, too ambitious, or just got buried under the daily chaos. If you’re tired of spinning your wheels, it’s time to take a smarter approach—literally. Enter SMART goals —your secret weapon for turning ideas into reality. Whether you’re looking to improve employee retention, streamline operations, or boost revenue, this framework ensures your goals don’t just sound good but actually get done . The SMART Formula for Success Specific – Get laser-focused. A goal like “improve employee morale” is too broad. Instead, ask yourself: What does success look like? Are you reducing turnover? Increasing engagement scores? Define it. Measurable – Numbers don’t lie. How will you know if you’ve succeeded? Instead of saying, “increase engagement,” set a target: “Boost employee engagement scores by 5%.” Tracking progress keeps you accountable. Achievable – Dream big, but stay realistic. Sure, we’d all love zero employee turnover, but is it feasible? Probably not. However, reducing turnover by 15%? Now that’s a goal within reach. Relevant – Align with the bigger picture. Every goal should move your business forward. If your focus is employee retention, then prioritizing revenue growth over culture initiatives might not be the best move. Keep your goals aligned. Time-Bound – Set the clock. “Improve retention” is a nice thought, but without a deadline, it’s just wishful thinking. Instead, say, “Increase retention by 5% by the end of the year.” A firm timeline drives action. Track It or Lose It A goal without tracking is just a wish. You wouldn’t set out on a road trip without checking the map, so why leave your goals to chance? Regular progress check-ins—whether through weekly reports, monthly reviews, or real-time dashboards—help keep you on course. Tracking not only highlights wins but also flags roadblocks early, giving you the chance to pivot before it’s too late. And here’s the key: don’t just track for the sake of tracking—use the data to refine your approach. For example, imagine you're aiming to improve employee engagement scores by 5% by the end of the year. After tracking progress for a few months, you notice that engagement is lagging in one department. Instead of waiting until the year-end review, you dig deeper. Perhaps it’s due to lack of recognition or unclear communication—adjustments are made, and suddenly, the department starts seeing improvement. Tracking allows you to course-correct in real-time, ensuring that you hit your target rather than missing the mark. The most successful businesses aren’t the ones that never face setbacks—they’re the ones that track, adapt, and push forward. How We Use SMART Goals to Stay Ahead At Simco, we don’t just talk about SMART goals—we live by them. Our team follows the Entrepreneurial Operating System (EOS) , which helps us stay focused, aligned, and results-driven. A big part of EOS is setting Rocks —key priorities for the next 90 days. And guess what? Every Rock follows the SMART framework: Clearly defined objectives Measurable success markers Challenging yet attainable goals Aligned with our company vision Locked in with a firm 90-day deadline This system keeps us accountable, making sure we’re always moving the needle in the right direction. Your Turn: Take Action Today No more “someday” goals— today is the day to take control. Whether you’re aiming to increase revenue, refine your processes, or boost employee satisfaction, the SMART approach ensures you’re not just busy—you’re making real progress. Need help aligning your HR, payroll, or benefits strategy with your business goals? Simco is here to help . Let’s make this your most productive quarter yet!
April Fools' Day is often the perfect opportunity for some lighthearted fun at the office. Whether it's a harmless prank, a funny email, or a playful desk setup, these moments of levity can help break up the monotony of the workday and bring smiles to your team. However, as many HR professionals know, it’s essential to strike a balance between fun and professionalism. While the intention behind pranks is typically harmless, they can sometimes cross boundaries and lead to uncomfortable situations, or worse, legal risks. Recently, an example came to light where one employee thought it would be funny to place a suggestive image on a coworker's desk. The issue arose when another employee saw the image and was offended, leading to a formal complaint. This scenario highlights the importance of knowing where to draw the line between lighthearted fun and inappropriate behavior. A Fine Line: When Fun Turns into Harassment Even if a prank isn't directly targeted at the offended person, it can still create a hostile work environment, especially if it makes someone uncomfortable. As an employer, it's crucial to ensure that your workplace remains respectful and free from harassment. If a prank results in a complaint, it's essential to follow your company's policies to investigate and address the situation. Proper documentation of your investigation and the actions taken is vital to demonstrate that you've fulfilled your obligations as an employer and to protect the organization in case of any future disputes. Setting Clear Expectations To avoid similar issues in the future, it's a good idea to review and clarify your company's stance on pranks and personal conduct in the workplace. Setting expectations starts with having a clear written policy that outlines what is and isn’t acceptable behavior, especially regarding pranks. Consider creating a set of guidelines that all employees can refer to, and be sure these expectations are communicated effectively to everyone. Here are a few tips to guide you: Establish a Formal Policy: Clearly define the boundaries of acceptable humor in your workplace. The policy should cover both pranks and jokes, specifying that while fun is encouraged, it should not come at the expense of respect, inclusion, or professionalism. Communicate Expectations Clearly: Include these guidelines in your employee handbooks or conduct policies, and ensure they’re reviewed during onboarding. Hold periodic team meetings to remind everyone about the importance of maintaining a respectful environment and reinforcing your stance on pranks. Set the Tone from Leadership: Managers and leaders should set an example when it comes to humor in the workplace. They should demonstrate the type of jokes or pranks that are acceptable and ensure their actions align with company policy. Employees are more likely to follow suit when they see their leaders taking these matters seriously. Encourage Open Communication: Foster a culture where employees feel comfortable speaking up if they feel a joke or prank crosses the line. Providing a safe outlet to discuss concerns without fear of retribution will help create an open, transparent environment where everyone feels heard. Categories of Pranks and Jokes That Cross the Line While there’s no one-size-fits-all approach, there are certain categories of pranks and jokes that should generally be off limits in the workplace . These pranks have the potential to cause harm, create discomfort, or violate company policies. By categorizing these behaviors, you can help employees better understand where to draw the line. Sexual or Gender-Based Humor : Avoid pranks with suggestive content, gestures, or language that can create a hostile work environment or be considered harassment. Discriminatory Jokes : Refrain from jokes targeting someone's race, religion, gender, sexual orientation, or other protected characteristics, as they can be harmful and illegal.  Invasive Pranks : Don’t tamper with personal belongings or invade others' personal space, as this undermines comfort and respect. Work Disruptions : Pranks that interfere with productivity or damage equipment should be avoided, as they can hurt overall efficiency. Aggressive or Harmful Pranks : Any prank that causes physical harm or emotional distress, including pranks involving physical touch or intimidation, is off-limits. Creating a Culture of Respect and Fun The key to managing pranks and other fun activities is to cultivate a workplace culture where employees feel comfortable, respected, and empowered. Rather than banning all pranks, focus on fostering a professional environment where employees understand the line between harmless fun and actions that could potentially harm or offend others. Encourage employees to engage in team-building activities and moments of levity that unite them in a positive and inclusive way, without crossing into territory that could lead to complaints or workplace tensions. As April Fools' Day passes, it’s important to remember that while pranks can provide a bit of comic relief, they should never come at the expense of respect or professionalism. By setting clear boundaries, encouraging open communication, and ensuring all employees understand your policies, you can create a workplace where everyone feels comfortable—whether they're laughing at a harmless joke or focusing on their next big project. Have fun in the workplace—but always ensure that a good laugh never comes at the expense of respect or professionalism!
