Is Medicare a primary or secondary payer?

If you have Medicare and other health or drug coverage, it’s important to know who will pay your bills first.

Here’s a look at what primary and secondary payer means, when Medicare is primary or secondary and how Medicare knows you have other coverage.

What does primary and secondary payer mean?

Each type of coverage you have is called a “payer.” When you have more than one payer, there are rules to decide who pays first, called the coordination of benefits. The “primary payer” pays what it owes on your bills first and sends the remaining amount to the second or “secondary payer.” There may also be a third payer in some cases.1

Important facts to know include:2

  • The primary payer pays up to the limits of its coverage.
  • The secondary payer only pays if there are costs the first payer didn’t cover.
  • The secondary payer (which could be Medicare) might not pay all of the uncovered cost.
  • If Medicare is the primary payer and your employer is the secondary payer, you’ll need to join Medicare Part B (medical coverage) before your employer insurance will pay for Part B services.

When is Medicare primary or secondary?

A number of things can affect when Medicare pays first. The following chart explains some common scenarios.3 For information on several other scenarios, check out how Medicare works with other insurance, opens new window.

Scenario Who pays first You’re 65 or older and have retiree insurance (insurance from former employment) Medicare You’re 65 or older, have group health plan coverage based on your or your spouse’s current employment and the employer has 20 or more employees Your group health plan You’re 65 or older, have group health plan coverage based on your or your spouse’s current employment and the employer has less than 20 employees Medicare You’re under 65 and disabled, have group health plan coverage based on your or a family member’s current employment and the employer has 100 or more employees Your group health plan You’re under 65 and disabled, have group health plan coverage based on your or a family member’s current employment and the employer has less than 100 employees Medicare

How does Medicare know if I have other coverage?

Medicare doesn’t automatically know if you have other coverage. But your insurers must report to Medicare when they’re the primary payer on your medical claims.

In some situations, your healthcare provider, employer or insurer may ask questions about your current coverage and report that information to Medicare.4 You also may be asked about other coverage at the time of enrollment.

Where to get more details

If you have additional questions about who pays your Medicare bills first, contact your insurance provider or call Medicare’s Benefits Coordination & Recovery Center (BCRC) at 855-798-2627 (TTY: 855-797-2627).

Sources

  1. “How Medicare Works with Other Insurance,” Medicare.gov, last accessed August 11, 2020, https://www.medicare.gov/supplements-other-insurance/how-medicare-works-with-other-insurance, opens new window.
  2. “How Medicare Works with Other Insurance.”
  3. “Coordination of Benefits: Getting Started,” Centers for Medicare & Medicaid Services, last accessed August 11, 2020, https://www.medicare.gov/Pubs/pdf/11546-coordination-of-benefits.pdf, opens new window.
  4. “Your Guide to Who Pays First,” Centers for Medicare & Medicaid Services, last accessed August 11, 2020, https://www.medicare.gov/Pubs/pdf/02179-medicare-coordination-benefits-payer.pdf, opens new window.

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