Is Medicare the Primary or Secondary Payer for Your Group?

For Washington small groups, our online quoting system will soon ask you to confirm whether Medicare is the primary or secondary payer for employees 65 or older. To determine this, you must know your employer size.

Medicare secondary payer status affects small group rates in Washington for employers with individuals age 65 or older enrolled in their group health plan. Currently, Oregon rates are not affected by this rule.

The rule of 20 or more

  • Medicare is the secondary payer if the employer has had 20 or more employees in each of 20 or more calendar weeks in the current or preceding calendar year. The 20 calendar weeks do not have to be consecutive.
  • Medicare is the primary payer if the employer did not have 20 or more employees in each of 20 or more calendar weeks in the current or preceding calendar year.
  • It is important that you count the total number of employees for all entities on the tax return.

Your employee count should be the total number of nationwide full-time employees, part-time employees, seasonal employees and partners who work or who are expected to report for work on a particular day. Do not count retirees, COBRA-qualified beneficiaries and individuals on other continuation options, and self-employed individuals who participate in the employer's group health plan.

Different rules apply for coordination of benefits for Medicare-eligible disabled beneficiaries and those with end-stage renal disease, but these do not affect rates in either Oregon or Washington.

We also will be reaching out to groups and following up with you soon to describe how these rules apply to new Medicare secondary payer reporting requirements that affect all groups.

For complete information about Medicare secondary payer guidelines, consult The Centers for Medicare & Medicaid Service's Medicare Secondary Payer Manual.