Do I need Medicare if I have insurance through my employer?
Which plan pays first depends on your employer's size, and getting it backwards leaves you holding bills you assumed were covered.
Having employer insurance at 65 does not automatically mean you can skip Medicare. What matters is which plan pays first, and that is decided by how many people your employer has.
Coordination of benefits, in one paragraph
When you have two sources of coverage, one is primary and pays first, and the other is secondary and picks up some of what is left. If the plan that is supposed to be primary is not in place, the secondary plan can still pay only its secondary share. The difference lands on you.
20 or more employees
Your group plan is primary. Medicare is secondary.
You can delay Part B without penalty for as long as you are actively working and covered. Most people still take premium free Part A, which can act as secondary coverage on hospital bills at no cost.
The exception is a Health Savings Account. Enrolling in any part of Medicare, including Part A alone, ends your ability to contribute.
Fewer than 20 employees
Medicare is primary. Your group plan is secondary.
This is the situation that hurts people. If you have not enrolled in Part B, your group plan can process claims as though Medicare had already paid its 80 percent, and then pay only its portion of what remains. You are responsible for the piece Medicare would have covered, even though you never had Medicare.
Small employers are common in South Texas. If your company is under 20 employees, get written confirmation from the plan administrator about how it coordinates with Medicare before you decide anything. A verbal reassurance from a coworker is not confirmation.
The count is not always obvious
The 20 employee threshold is measured across the employer, not your location, and it generally means 20 or more employees for at least 20 weeks in the current or prior calendar year. Part time employees usually count.
If you work at a small branch of a large company, the large company's count is what applies. Ask HR to confirm in writing.
Special situations with different rules
- Coverage based on disability rather than age uses a 100 employee threshold instead of 20.
- End stage renal disease has its own coordination timeline, generally 30 months of group plan primacy.
- Retiree coverage is always secondary to Medicare, no matter the employer's size. If you are on retiree coverage, you need Part B.
- COBRA is also secondary. Do not treat it as employer coverage for delay purposes.
Do not forget the drug side
Separately from all of the above, your employer plan should send you a notice each fall stating whether its prescription coverage is creditable, meaning at least as good as Part D. Keep those notices. If the coverage is not creditable, a Part D penalty accrues whether anyone warned you or not.
The short version
- Find out the employee count and get it in writing.
- 20 or more and actively working: you can usually delay Part B safely.
- Under 20, or on retiree coverage or COBRA: you almost certainly need Part B now.
- Contributing to an HSA: stop at least six months before enrolling in anything.
- Either way, keep the creditable coverage notice.
For the enrollment mechanics when you do retire, see applying for Medicare after 65.
Common follow-up questions
My employer has 8 employees and I did not take Part B. What happens?
Your group plan may pay only as secondary, leaving you the share Medicare would have paid. Enroll in Part B as soon as possible and check with the plan administrator about claims already processed.
Does my spouse's employer coverage count?
Yes, if that spouse is actively working and the employer meets the size threshold. Retired spouse coverage does not count.
Is retiree coverage the same as employer coverage?
No. Retiree coverage is always secondary to Medicare regardless of company size, so you need Part B alongside it.
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