How will Medicare function for a 70-year-old insured with kidney failure covered by a spouse’s large-group employer plan?

In this scenario, Medicare will function as the secondary insurer for the 70-year-old individual with kidney failure who is also covered by a spouse’s large-group employer plan. When a person is covered by both Medicare and a group health plan from an employer with more than 20 employees, the group health plan typically pays first. This is because the employer plan is considered primary in coordinating benefits, which means it will cover the healthcare costs before Medicare starts to pay.

Once the primary plan has processed the claims and made payments, Medicare will then cover additional costs according to its coverage rules, thus acting as the secondary insurer. This coordination helps ensure that the insured receives comprehensive coverage by utilizing both the employer plan and what Medicare offers, thereby reducing potentially out-of-pocket expenses for the insured.

Understanding how the primary and secondary insurances work is crucial for maximizing health benefits and managing healthcare costs effectively.