Who Is Responsible To Ensure My Medigap Plan Pays What Medicare Doesn’t?

Medicare participants need to understand that both plans; original Medicare plan and Medigap plans have predetermined deductible and coinsurance amounts or out of pocket expenses. Medicare will pay its share of the covered services and Medigap Medicare supplemental plan pays its share according to the selected plan. Most Medigap plans for supplement pay for coinsurance amounts and some portion of the Medicare deductible requirements.


Medicare original is usually the primary payer for Medicare participants and the secondary payer is generally Medigap plan for Medicare supplement insurance. When the Medicare participant visits the doctor or hospital the two Medicare plans organize how the payments are made, with the first or primary payer paying their share and forwarding the secondary payer’s share for payment. In some cases there may be a third payer, and the Medicare participant needs to advise the medical service provider with the information. Accurate information will help to prevent delays in getting each payer’s share paid.


There may be circumstances where Medicare original is not the primary payer even though the Medicare participant is entitled to Medicare coverage. In these cases, the primary may be other supplemental plans, or group plans and Medicare may agree to conditional payments. If the Medicare participant is entitled to Medicare, and also covered under a group plan, Medicare becomes the secondary payer. Any costs not paid for between the group plan and Medicare original will need to be forwarded to the third payer, Medicare supplement plan.


Medicare requires that the Medicare participant update the medical insurance coverage information. Providing the information will assist with medical claim processing, ensure that payments are made accurately and on a timely basis.

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