COB Playbook

Medicare Eligibility vs. Entitlement

Individual Policies People often mix up these two terms when discussing Medicare. The difference between the two is:  Being eligible means a patient is qualified for Medicare, meets one of the conditions for coverage and would receive it if they applied.  Being entitled means a patient is qualified for Medicare, meets one of the conditions for coverage, has applied and a Medicare ID number was issued. Coverage is active. We learned in All About Insurance that if a patient has an individual policy, Medicare will always be primary. Sometimes when verifying coverage, an insurance representative will mention “individual” when discussing benefits. In order for us to determine the possibility of a COB, it is important for us to ask questions to clarify during the call:  Is this an Individual plan that is privately purchased and not through an EGHP? (in which case Medicare would always be primary) OR  They are calling it Individual because the policy holder has no spouse or dependents on the plan. In this case, it is truly a group health plan (EGHP), and there could be a possibility of a COB.