Is Medicare Primary or Secondary Insurance (2024)

FAQs

Is Medicare a primary or secondary insurance? ›

Primary payers are those that have the primary responsibility for paying a claim. Medicare remains the primary payer for beneficiaries who are not covered by other types of health insurance or coverage. Medicare is also the primary payer in certain instances, provided several conditions are met.

When it comes to primary versus secondary insurance, the question of who pays first depends on the situation. For example, if you're a child with two parents who both cover you under their respective family plans, your primary insurance is decided by something called “the birthday rule”.

To determine which plan is primary, which means the insurer pays for covered services first according to the benefits provided by the plan. The other insurer pays secondary, which means it pays the remaining unpaid balance according to the benefits provided by its plan.

Providers are required to complete a Medicare Secondary Payer Questionnaire (MSPQ) upon admission of each Medicare patient. A sample of the MSPQ can be found in the Centers for Medicare & Medicaid Services' (CMS) Internet-Only Manual (IOM), Publication 100-05, Medicare Secondary Payer Manual, Chapter 3, Section 20.2.

If you work for a company with fewer than 20 employees, Medicare is considered your primary coverage. That means Medicare pays first, and your employer coverage pays second. If you work for a larger company, your employer-based coverage will be your primary coverage and Medicare your secondary coverage.

If the group health plan doesn't pay all of a bill, the doctor or health care provider should send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn't cover.

Always send the claim to the primary payer first. If the primary payer denies the claim because of liability, the no-fault or WC insurer must place the reason for denial on the claim, which you can find on your remittance advice that you'll send to Medicare. Without this reason, Medicare will deny the claim.

A credit balance results when the secondary payer allows and pays a higher amount than the primary insurance carrier. This credit balance is not actually an overpayment. The amount contractually adjusted off from the primary insurance carrier was more than needed, based on the secondary insurance carrier's payment.

Example: Patient's mother's birthday is October 11, and patient's father's birthday is April 24. In this case, the father's insurance would be the primary insurance and the mother's insurance would be the secondary. If the parents share a birthday, the primary plan would be the plan which has been effective longer.

Usually, secondary insurance pays some or all of the costs left after the primary insurer has paid (e.g., deductibles, copayments, coinsurances). For example, if Original Medicare is your primary insurance, your secondary insurance may pay for some or all of the 20% coinsurance for Part B-covered services.

Which insurance is primary when you have two? ›

You don't choose which plan is primary. That is set by the coordination of benefits rules. Usually, your employer's plan is primary. If you also are covered by your spouse's plan, that plan is usually secondary.

Can I combine employer health insurance with Medicare? If you or your spouse are working and covered through an employer, you can also decide to keep this coverage and enroll in Original Medicare, Part A and/or Part B to get additional health coverage.

Medicare regulations require providers who submit Medicare claims to determine whether Medicare is the primary payer or secondary payer for items or services furnished to a beneficiary.

CMS developed tools, including an MSP model questionnaire, Admissions Questions to Ask Medicare Beneficiaries, to help providers identify the correct primary claims payers for all beneficiary-furnished services in a hospital.

Providers may use this as a guide to help identify other payers that may be primary to Medicare. This questionnaire is a model of the type of questions that may be asked to help identify Medicare Secondary Payer (MSP) situations.

When an individual has both Medicare Parts A and B, Medicare is the primary insurance and pays for most medical care. Medi-Cal is the secondary insurance, and it pays for costs not covered by Medicare and provides additional benefits not covered by Medicare.

Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private company that helps pay your share of costs.