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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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Overview of the New Ruling New York employers are once again required to provide a notice in their employee handbooks about reproductive health rights following a recent ruling from the U.S. Court of Appeals for the Second Circuit. The ruling vacated a previous permanent injunction that had blocked the enforcement of the law, meaning employers must now comply with the New York Reproductive Health Bias Law (Labor Law § 203-e). Reproductive Health Bias Law Requirements The Reproductive Health Bias Law was enacted in November 2019 to ensure employees and their dependents can make reproductive health decisions without facing discrimination in the workplace. The law prohibits employers from taking retaliatory actions against employees regarding their reproductive health decisions and requires employers to keep employees' reproductive health information confidential unless there is prior written consent. Under the law, employers must include a notice in their employee handbooks informing employees of their rights and remedies under the Act. This is an essential update that must be made to comply with the law. Impact of the Second Circuit Ruling Religious organizations had challenged the law, arguing that the notice requirement violated their First Amendment rights. However, the Second Circuit disagreed, ruling that the notice requirement was lawful and similar to other workplace disclosure laws. The court noted that while the policy motivating the law may be controversial, the law itself and the obligation for employers to comply are not in question. Action Required for Employers Even though there is no specific penalty for failing to comply with the notice requirement, employers are encouraged to review and update their employee handbooks in light of the court's ruling to ensure they are compliant with the law. For Simco Clients: For clients who utilize Simco’s employee handbook services, rest assured this requirement is already included, and no additional steps are needed.
Pre-employment drug testing is a hiring practice that has sparked debate in recent years. While some industries rely on it for safety and compliance, others are rethinking its necessity—especially as marijuana laws evolve. If you're actively job searching, knowing what to expect can help you prepare, avoid surprises, and understand your rights. Who Still Requires Drug Testing? Not all industries conduct pre-employment drug testing, but for certain roles, it's still a non-negotiable requirement. Some of the most common sectors where testing remains standard include: Transportation & Public Safety – Truck drivers, pilots, transit operators, and law enforcement Healthcare & Childcare – Nurses, physicians, pharmacists, and daycare providers Government & Military Contracts – Federal employees, military personnel, and defense contractors Manufacturing & Construction – Heavy equipment operators and industrial workers handling hazardous materials However, policies vary widely even within these industries. Some companies are now loosening restrictions for non-safety-sensitive positions, recognizing that outdated drug testing policies may limit their talent pool. What Substances Are Typically Screened? Most pre-employment drug tests screen for common illicit substances, but the depth of testing can vary. Standard screenings include: Five-Panel Test – Detects marijuana, cocaine, amphetamines, opiates, and PCP Expanded Panel Tests – Can include benzodiazepines, barbiturates, synthetic opioids, and even alcohol Employers may use different types of tests, including urine, saliva, blood, or hair follicle analysis. Hair follicle testing, for example, can detect drug use from months prior—something applicants should be mindful of. The Evolving Landscape of Marijuana Testing One of the most significant changes in pre-employment drug testing involves marijuana. With over half of U.S. states legalizing marijuana in some form, companies are reevaluating their stance. Some states prohibit employers from disqualifying candidates for off-duty marijuana use. Other states still allow testing but require employers to prove impairment, not just presence. Federally regulated positions, such as those in transportation, maintain strict no-tolerance policies. This shift means that while some applicants may no longer face automatic disqualification for marijuana use, it’s still important to know an employer’s policy before assuming it won’t impact hiring decisions. What Happens If You Fail a Pre-Employment Drug Test? The consequences of failing a drug test depend on multiple factors, including company policy, industry regulations, and state laws. In regulated industries (e.g., transportation, healthcare, federal employment), a failed test almost always results in immediate disqualification. Some employers allow re-testing or a waiting period before reapplying, particularly for marijuana use in certain states. If you have a valid prescription for a tested substance (e.g., opioids or ADHD medication), you may need to provide documentation to avoid disqualification. Additionally, some companies offer assistance programs or second-chance policies, especially if an applicant is upfront about past use or addiction recovery. Do Employers Really Benefit from Drug Testing? With the workforce evolving, many companies are questioning whether traditional drug testing policies still serve their intended purpose. Some argue that testing reduces liability, improves workplace safety, and ensures reliable employees. However, others believe that outdated policies exclude qualified candidates, especially in a competitive job market. The Arguments for Drug Testing: Reduces workplace accidents in safety-sensitive roles Ensures compliance with federal and industry regulations Discourages drug use in high-responsibility positions The Arguments Against Drug Testing: May eliminate qualified candidates for non-safety-sensitive roles Does not account for impairment vs. past use (especially with marijuana) Can be costly and time-consuming for employers Companies that still require drug testing must weigh these factors and ensure their policies align with modern workforce expectations. The Future of Pre-Employment Drug Testing The debate over drug testing isn’t going away anytime soon. As laws and attitudes continue shifting, companies may move toward impairment-based testing rather than zero-tolerance screening. This means job seekers should stay informed, especially in industries where testing is likely to remain a requirement. For now, the best approach is to understand employer expectations, know your legal protections, and be prepared for potential screenings as part of the hiring process.
Workplace Posting for Form 300A Begins February 1 Employers with 11 or more employees at any point in 2024 must display the Occupational Safety and Health Administration (OSHA) Form 300A, Summary of Work-Related Injuries and Illnesses, from February 1 to April 30. Even if no recordable incidents occurred in 2024, this posting is mandatory. The form must be certified by a company executive and displayed prominently in each workplace where employee notices are typically posted. Certain businesses are exempt from OSHA’s regular recordkeeping requirements, including this posting, if they employ 10 or fewer people or if their primary business activity is considered low hazard according to OSHA's guidelines. A full list of low-hazard industries, categorized by NAICS codes, is available here . However, even exempt companies must report fatalities or incidents resulting in hospitalization, amputation, or loss of an eye. Electronic Submission of Form 300A Due by March 2 Businesses with 250 or more employees from the previous year, or those with 20-249 employees in high-risk industries, must submit their Form 300A data electronically through OSHA's Injury Tracking Application (ITA) by March 2, 2025. This requirement applies based on the number of employees at a specific location, not the entire company. Employers under State Plans are also required to submit electronically. Exemptions from this electronic submission apply to employers who: Are exempt from OSHA's regular recordkeeping rules. Had fewer than 20 employees in the past year. Had between 20 and 249 employees but aren’t in the designated high-risk industries. Additional resources, FAQs, and access to the ITA are available on OSHA’s ITA page . Submission of Forms 300 and 301 Required by March 2 Employers in high-hazard industries with 100 or more employees are required to submit data from both their Form 300 (Log of Work-Related Injuries and Illnesses) and Form 301 (Injury and Illness Incident Report) through the ITA, in addition to their Form 300A submission. Help with Coverage Determination Employers can use OSHA’s ITA Coverage Application to assess whether they need to submit injury and illness data electronically or refer to the State Plan for specific reporting requirements.
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Overview of the New Ruling New York employers are once again required to provide a notice in their employee handbooks about reproductive health rights following a recent ruling from the U.S. Court of Appeals for the Second Circuit. The ruling vacated a previous permanent injunction that had blocked the enforcement of the law, meaning employers must now comply with the New York Reproductive Health Bias Law (Labor Law § 203-e). Reproductive Health Bias Law Requirements The Reproductive Health Bias Law was enacted in November 2019 to ensure employees and their dependents can make reproductive health decisions without facing discrimination in the workplace. The law prohibits employers from taking retaliatory actions against employees regarding their reproductive health decisions and requires employers to keep employees' reproductive health information confidential unless there is prior written consent. Under the law, employers must include a notice in their employee handbooks informing employees of their rights and remedies under the Act. This is an essential update that must be made to comply with the law. Impact of the Second Circuit Ruling Religious organizations had challenged the law, arguing that the notice requirement violated their First Amendment rights. However, the Second Circuit disagreed, ruling that the notice requirement was lawful and similar to other workplace disclosure laws. The court noted that while the policy motivating the law may be controversial, the law itself and the obligation for employers to comply are not in question. Action Required for Employers Even though there is no specific penalty for failing to comply with the notice requirement, employers are encouraged to review and update their employee handbooks in light of the court's ruling to ensure they are compliant with the law. For Simco Clients: For clients who utilize Simco’s employee handbook services, rest assured this requirement is already included, and no additional steps are needed.
Pre-employment drug testing is a hiring practice that has sparked debate in recent years. While some industries rely on it for safety and compliance, others are rethinking its necessity—especially as marijuana laws evolve. If you're actively job searching, knowing what to expect can help you prepare, avoid surprises, and understand your rights. Who Still Requires Drug Testing? Not all industries conduct pre-employment drug testing, but for certain roles, it's still a non-negotiable requirement. Some of the most common sectors where testing remains standard include: Transportation & Public Safety – Truck drivers, pilots, transit operators, and law enforcement Healthcare & Childcare – Nurses, physicians, pharmacists, and daycare providers Government & Military Contracts – Federal employees, military personnel, and defense contractors Manufacturing & Construction – Heavy equipment operators and industrial workers handling hazardous materials However, policies vary widely even within these industries. Some companies are now loosening restrictions for non-safety-sensitive positions, recognizing that outdated drug testing policies may limit their talent pool. What Substances Are Typically Screened? Most pre-employment drug tests screen for common illicit substances, but the depth of testing can vary. Standard screenings include: Five-Panel Test – Detects marijuana, cocaine, amphetamines, opiates, and PCP Expanded Panel Tests – Can include benzodiazepines, barbiturates, synthetic opioids, and even alcohol Employers may use different types of tests, including urine, saliva, blood, or hair follicle analysis. Hair follicle testing, for example, can detect drug use from months prior—something applicants should be mindful of. The Evolving Landscape of Marijuana Testing One of the most significant changes in pre-employment drug testing involves marijuana. With over half of U.S. states legalizing marijuana in some form, companies are reevaluating their stance. Some states prohibit employers from disqualifying candidates for off-duty marijuana use. Other states still allow testing but require employers to prove impairment, not just presence. Federally regulated positions, such as those in transportation, maintain strict no-tolerance policies. This shift means that while some applicants may no longer face automatic disqualification for marijuana use, it’s still important to know an employer’s policy before assuming it won’t impact hiring decisions. What Happens If You Fail a Pre-Employment Drug Test? The consequences of failing a drug test depend on multiple factors, including company policy, industry regulations, and state laws. In regulated industries (e.g., transportation, healthcare, federal employment), a failed test almost always results in immediate disqualification. Some employers allow re-testing or a waiting period before reapplying, particularly for marijuana use in certain states. If you have a valid prescription for a tested substance (e.g., opioids or ADHD medication), you may need to provide documentation to avoid disqualification. Additionally, some companies offer assistance programs or second-chance policies, especially if an applicant is upfront about past use or addiction recovery. Do Employers Really Benefit from Drug Testing? With the workforce evolving, many companies are questioning whether traditional drug testing policies still serve their intended purpose. Some argue that testing reduces liability, improves workplace safety, and ensures reliable employees. However, others believe that outdated policies exclude qualified candidates, especially in a competitive job market. The Arguments for Drug Testing: Reduces workplace accidents in safety-sensitive roles Ensures compliance with federal and industry regulations Discourages drug use in high-responsibility positions The Arguments Against Drug Testing: May eliminate qualified candidates for non-safety-sensitive roles Does not account for impairment vs. past use (especially with marijuana) Can be costly and time-consuming for employers Companies that still require drug testing must weigh these factors and ensure their policies align with modern workforce expectations. The Future of Pre-Employment Drug Testing The debate over drug testing isn’t going away anytime soon. As laws and attitudes continue shifting, companies may move toward impairment-based testing rather than zero-tolerance screening. This means job seekers should stay informed, especially in industries where testing is likely to remain a requirement. For now, the best approach is to understand employer expectations, know your legal protections, and be prepared for potential screenings as part of the hiring process.
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