Insurance plans offered through the Small Business Health Options Program (SHOP) are job-based insurance plans purchased through the Marketplace. SHOP allows businesses with fewer than 50 employees and their employees to search for and buy health coverage. SHOP plans follow the same rules as other insurance based on current work. Your plan is primary or secondary depending on: the size of your employer and whether your Medicare eligibility is based on age, disability, or End-Stage Renal Disease (ESRD).

  • If you are eligible for Medicare due to age and your employer has:
    • 20 or more employees, your SHOP plan pays primary
    • Fewer than 20 employees, your SHOP plan pays secondarY
  • If you are eligible for Medicare due to disability, your SHOP plan will always pay secondary

If you like your SHOP plan and it is primary, you can choose to delay Medicare enrollment. Be sure to compare your plan’s costs and coverage to Medicare’s and make the decision that is best for you. If your SHOP plan is secondary, you may want to enroll in Medicare because your SHOP plan may pay little to nothing for your care. In either case, you have a Special Enrollment Period (SEP) to enroll in Part B.

SHOP plans may also offer creditable drug coverage. If your SHOP plan drug coverage is creditable, you can choose to delay Part D enrollment without penalty. If you decide to delay taking Part D, keep a record of your insurance until you enroll in Medicare. You may need this documentation in order to sign up for Part D later.

You should talk to your employer to see whether you need Medicare in addition to your SHOP coverage. After speaking to your employer, confirm what you have learned with the Social Security Administration (800-772-1213). Get all answers in writing.

Note: There are different rules for individuals who are Medicare-eligible due to End-Stage Renal Disease.

Return to: Medicare Admin

This content was created and copyrighted by the Medicare Rights Center ©2020. Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities. These materials are presented here with support from YourMedicare.com and may not be distributed, modified or edited without Medicare Rights’ consent.

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