What is a Medicare Secondary Payer?

Medicare secondary payer is a term used when you are covered by Medicare but some other insurer has the primary responsibility of paying your medical bill. Medicare becomes the secondary payer, paying only after the other insurer has met its responsibility.

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Terry Turner
Terry Turner
Senior Financial Writer and Financial Wellness Facilitator
Terry Turner has more than 35 years of journalism experience, including covering benefits, spending and congressional action on federal programs such as Social Security and Medicare. He is a Certified Financial Wellness Facilitator through the National Wellness Institute and the Foundation for Financial Wellness and a member of the Association for Financial Counseling & Planning Education (AFCPE®).
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Lee Williams
Lee Williams
Senior Financial Editor
Lee Williams is a professional writer, editor and content strategist with 10 years of professional experience working for global and nationally recognized brands. He has contributed to Forbes, The Huffington Post, SUCCESS Magazine, AskMen.com, Electric Literature and The Wall Street Journal. His career also includes ghostwriting for Fortune 500 CEOs and published authors.
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Joe Benish
Joe Benish
Licensed Agent at Insuractive
As a licensed insurance agent specializing in providing seniors with Medicare-related products, Joe Benish knows how daunting it can be to learn about Medicare and all of the options available. That’s why he spends his time getting to know his clients and helping them select the right plans for them from the more than 15 insurance companies he represents.
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Published: October 19, 2020
Updated: May 8, 2023
6 min read time
This page features 9 Cited Research Articles

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What Does Secondary Payer Mean When You Are on Medicare?

Primary and secondary payers come into play when you have Medicare and some other type of medical or hospital insurance such as an employer group insurance plan, Veterans Affairs benefits, or workers’ compensation.

Difference Between Primary and Secondary Payers

Primary payer: Primary payers are the insurer or program that has the primary responsibility of paying for your health care claim. They pay up to the limit or your coverage under your plan.
Secondary payer: Secondary payers are the insurer or program that pays second, and it only pays if there are still costs after the primary payer has paid its share. But even after the secondary payer pays its share, you may still have out-of-pocket costs.

Medicare has a process called coordination of benefits that determines who the primary and secondary payers are in your case, and how they pay your claims.

Common Primary Payers

COBRA: The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you the right to choose to keep your and your family’s health insurance through an employer for a limited time if you lose your job, change jobs or in certain other situations.
Department of Veterans Affairs (VA) benefits: VA health benefits are provided to certain veterans who served in the active duty military and did not receive a dishonorable discharge.
Group health plans: These are health insurance plans or other medical benefits provided through your or your spouse’s employer or an employee organization such as a union.
Liability insurance: This is insurance carried by the person at fault for an accident that pays for health care for others injured in the accident.
No-fault insurance: Also called personal injury protection or PIP coverage, it helps pay the cost of medical expenses for you and your passengers following a car crash whether you are at fault or not.
Retiree health insurance: This is insurance provided through your former employer after you retire.
Tricare: This is the federal health care program for uniformed service members, retirees and their families.
Workers’ compensation: Workers’ compensation is business insurance that provides coverage for health care costs and lost wages due to work-related injuries or illnesses.

When Is Medicare a Primary Payer or a Secondary Payer?

Medicare is usually the secondary payer when you have other coverage. But Medicare is the primary payer if you do not have other coverage and is also the primary payer in certain circumstances if several conditions are met.

Examples of Primary Payer vs. Secondary Payer Situations

Person	Situation	Primary Payer	Secondary Payer
65 or older and covered by a group health plan through a job or spouse’s job	Entitled to Medicare and the employer has fewer than 20 employees	Medicare	Group health plan
	Entitled to Medicare and the employer has more than 20 employees	Group health plan	Medicare
65 or older and is a retiree covered by an employer group health plan	Qualified for Medicare	Medicare	Group health plan
Active duty military member	Entitled to both Medicare and Tricare	Tricare	Medicare
Inactive duty military member treated by a military or other federal health care provider	Entitled to both Medicare and Tricare	Tricare	Medicare
Inactive duty military member treated by civilian health care provider	Entitled to both Medicare and Tricare	Medicare	Tricare
Has End-Stage Renal Disease (ESRD) and a group health plan or COBRA coverage	First 30 months of Medicare eligibility	Group health plan or COBRA	Medicare
	After first 30 months of Medicare eligibility	Medicare	Group health plan or COBRA
Injured in an accident covered by no-fault liability insurance	Entitled to Medicare	Workers’ compensation, no-fault or liability insurance	Medicare (except in cases of ongoing medical care, in which Medicare does not pay)

Source: Centers for Medicare & Medicaid Services

What to Do If Your Primary Payer Does Not Pay

If the primary payer fails to pay a medical claim, you may be able to request Medicare to make a conditional payment to cover the cost. Medicare will only make a conditional payment if there is “evidence that the primary plan does not pay promptly,” according to the Centers for Medicare and Medicaid Services.

Medicare will pay the bill, but you must take action to make the primary payer cover its share of the medical bill. This may require you to hire an attorney, file a lawsuit or take other legal action.

Examples of When You May Request a Conditional Payment from Medicare

Your group health plan denies payment because you exhausted your benefits, you are not entitled to benefits under the plan or the plan does not cover the services.
You receive medical services not directly related to the conditions for which you are receiving workers’ compensation benefits.
Your workers’ compensation program fails to pay within the “paid promptly” period — usually within 120 days of receiving the claim.
Your workers’ compensation plan denies coverage for services.
Your Workers’ Compensation Medicare Set-Aside Arrangement has been terminated or exhausted.

Questions about how to file a conditional payment request should be directed to Medicare’s Benefits Coordination and Recovery Center. You can call the center toll-free Monday through Friday from 8:00 am to 8:00 pm at 855-798-2627 (TTY at 855-797-2627).

Last Modified: May 8, 2023