COB Scenarios
Star Miller is 40 and enrolled into Medicare due to ESRD: 1.1.2005, transplant 3.22.2005 and failed and started dialysis 2.15.2009
When Does ESRD-based eligibility ends? What is the wait period? What is the Coordination of Benefits timeframe?
Return to dialysis after successful failed transplant, waiting period is waived.
ESRD entitlement ends 30 months after transplant (03.2008)
Star is entitled to 30 month COB when returning to dialysis. (New COB 02.2009-07.31.2011)
What are the COB rules for COBRA coverage if a person is MCARE entitled due to age/disability only?
Medicare is primary to COBRA coverage, regardless if a person elects COBR coverage before or after MCARE entitlement.
What are the COB rules for Retiree Coverage with Medicare entitlement due to age/disability only?
Group health plan may pay as secondary to Medicare after beneficiary becomes entitled to Medicare.
What are the COB rules for Active employment (self/spouse/dependent) with Medicare entitlement due to ESRD only OR dual entitlement ESRD then age/disability?
During the COB period, group health plan is primary and MCARE is secondary. After COB period, MCARE is primary. (GHP may agree to continue coverage as primary)
How long do you have to be a Legal Citizen to qualify for Medicare?
5 years
Star Miller is 40 started dialysis 10/5/2025, enrolled into Medicare 1.1.2026. Spouse is actively employed and covers Star Miller under GHP.
What is the coordination of benefits period? When would Medicare become primary?
33-Month COB, waiting period not waived.
COB ends 06/30/2028. MCARE primary 07/01/2028.
What are the COB rules if a person is entitled to Medicare due to ESRD only and they elect COBRA coverage AFTER Medicare entitlement?
COBRA will be primary as long as person elects COBRA policy.
What are the COB rules for Retiree Coverage with Medicare entitlement due to ESRD only or dually entitled ESRD then age/disability?
During the COB period, EGHP is primary and Medicare is secondary. After the COB period Medicare will become primary.
What is the Cardinal Rule?
If Medicare becomes primary at anytime and entitlement is disability or age, then MCARE remains primary.
How many work quarters are required at age 65 to be eligible for Medicare?
40 work quarters (10 years)
Mike Wazowsk was diagnosed ESRD on 10/1/2022 and started In-Center Hemodialysis at Cyclops Dialysis Center but regained renal function after 3 months. His kidney failed again and returned to dialysis 9/30/2025.
What is the waiting period? How long will be the COB?
Waiting period is waived if regained kidney function last 12+ months.
COB: 09/01/2025-02/28/2028
If a person is DUAL entitled due to ESRD/AGE and COBRA are effective on the same exact day, who is primary?
COBRA is primary
What happens if a persons retirement date is BEFORE FDODE?
EGHP is primary UNLESS a persons group health plan becomes a MCARE supplement plan.
What is the COB rules for Active employment (self/spouse/dependent) with Medicare entitlement due to age/disability only?
Group health plan and Medicare is secondary for the entire period of current employment coverage. (Size of employer will be a factor)
If a persons is covered under spouses active EGHP, and inactive thru self ( over 6 months on long term disability), who's play is primary?
Active employment over inactive.
What is Star Miller COB end date when her FDODE is 2.5.25, is age 50 at time and actively employed. She did not have training within 3 months. She lost her job on 2.28.25 and elected COBRA effective 3.1.25
No COB period. If patient elects COBRA coverage BEFORE Medicare entitlement, EGHP will pay secondary to Medicare during the COBRA coverage period.
If on long term disability, will you still have active employer group benefits?
No, employers are generally not required by law to maintain active group health insurance. Person may need to elect COBRA coverage
What are the COB rules for Retiree coverage with Medicare dual entitlement due to age/disability first then ESRD?
Group health plan may pay secondary to Medicare if the plan is a retiree supplement plan. ESRD COB rules will not trump EGHP secondary status.
What are the COB rules for a small group health plan when a person is dually entitled age/disability then ESRD)
What agency determines eligibility for Medicare? What file is used to update Medicare?
SSA will update the Common Working File (CWF) and based on that information Medicare assigns benefits.
Star Miller age 65 in 2.5.2005 had FDODE 6.5.2005, transplant 2.5.2010 returned to dialysis on 2.5.2025. When eligibility was checked, pt. had retirement policy and part A/B effective 2.1.2005
What is the current entitlement reason? Does the patient qualify for a new cob? if so, how long is cob period? What is the transplant success date?
Transplant success date 02/2013
Current entitlement: Dually entitled, Age then ESRD
New COB: Additional verification required, Cardinal Rule if Medicare was primary then it will remain primary.
If a person is MCARE entitled due to age/disability and COBRA are effective on the same exact day, who is primary?
Medicare is primary.
What happens if a person becomes entitled to Medicare and COBRA on the same day?
Medicare would be primary UNLESS entitlement is dual or ESRD, then COBRA is primary.
What happens if a person loses their qualifying EGHP plan during their COB period?
Medicare will be billed as primary, if the person obtains another qualifying EGHP plan it will become primary for the remainder of the COB period.
The patient is entitled to Medicare due to Age and Disability; Is this patient considered Dual entitled?
No. Patient would need to be age/disability AND ESRD to be considered dually entitled.