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.
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.
- 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.
- 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.
- 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.
|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)|
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.
- 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).
9 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2020, October 2). Workers’ Compensation Medicare Set Aside Arrangements. Retrieved from https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Overview
- U.S. Centers for Medicare & Medicaid Services. (2020, August). Medicare & Other Health Benefits: Your Guide to Who Pays First. Retrieved from https://www.medicare.gov/Pubs/pdf/02179-medicare-coordination-benefits-payer.pdf
- U.S. Centers for Medicare & Medicaid Services. (2020, August). Coordination of Benefits. Retrieved from https://www.medicare.gov/Pubs/pdf/11546-coordination-of-benefits.pdf
- U.S. Centers for Medicare & Medicaid Services. (2020, June 30). Medicare Secondary Payer. Retrieved from https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Medicare-Secondary-Payer/Medicare-Secondary-Payer
- U.S. Centers for Medicare & Medicaid Services. (2020, June 30). Medicare Secondary Payer Recovery Portal. Retrieved from https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/MSPRP/Medicare-Secondary-Payer-Recovery-Portal
- U.S. Centers for Medicare & Medicaid Services. (2020, June 30). Coordination of Benefits. Retrieved from https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of-Benefits-and-Recovery-Overview/Coordination-of-Benefits/Coordination-of-Benefits
- U.S. Centers for Medicare & Medicaid Services. (2020, April). Medicare Secondary Payer. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/msp_fact_sheet.pdf
- U.S. Centers for Medicare & Medicaid Services. (n.d.). How Medicare Works with Other Insurance. Retrieved from https://www.medicare.gov/supplements-other-insurance/how-medicare-works-with-other-insurance
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare Secondary Payer Recovery Portal. Retrieved from https://www.cob.cms.hhs.gov/MSPRP/assets/msprp/case/CondPymtAmt.htm