If you have Medicare and other health insurance or coverage, each type of coverage is called a "payer." When there is more than one payer, "coordination of benefits" rules decide which one pays first. The "primary payer" pays what it owes on your bills first, and then sends the rest to the "secondary payer" to pay. The insurance that pays first is called the primary payer. The primary payer pays up to the limits of its coverage. The insurance that pays second is called the secondary payer. The secondary payer only pays if there are costs the primary insurer didn't cover.
The Medicare Coordination of Benefits (COB) program wants to make sure Medicare pays your claims right the first time, every time. The Benefits Coordination & Recovery Center (BCRC) collects information on your health care coverage and stores it in your Medicare record. This record must be updated every time you make a change to your health care coverage. Information comes from these sources:
- Your Medicare Secondary Claim Development Questionnaire,
- Your doctor and other providers,
- Your group health plan,
- Your employer, and
- You.
Medicare may be your secondary payer. Your record should show whether a group health plan or other insurer should pay before Medicare. Paying claims right the first time prevents mistakes and problems with your health care plans. To ensure correct payment of your Medicare claims, you should:
- Respond to Medicare Secondary Claim Development Questionnaire letters in a timely manner.
- Tell the BCRC about any changes in your health insurance due to you, your spouse, or a family member’s current employment or coverage changes. The BCRC’s information can be accessed by clicking Contacts in the Related Links section below.
- Tell your doctor and other health care providers if you have coverage in addition to Medicare.
- Be aware that changes in employment, including retirement and changes in health insurance companies may affect your claims payment.
For more information on how Medicare works with other insurance, click the medicare.gov link found in the Related Links section below. Next, go to the “Supplements and Other Insurance” menu option at the top of the page and select “How Medicare works with other insurance” from the drop-down list. Additional information can be accessed by selecting the Coordination of Benefits link also found in the Related Links section.
Medicare Secondary Claim Development Questionnaire
The Medicare Secondary Claim Development Questionnaire is sent to obtain information about other insurers that may pay before Medicare. When you return the questionnaire in a timely manner, you help ensure correct payment of your Medicare claims.
This questionnaire is mailed when a claim is submitted to Medicare with an explanation of benefits (EOB) attached, a self-report is made by you or your attorney identifying a Medicare Secondary Payer (MSP) situation, or an insurer submits MSP information to a contractor, or the BCRC. This questionnaire asks:
- If you have other health insurance or coverage based upon your current employment;
- If you are receiving black lung benefits, workers' compensation benefits, or treatment for an injury or illness for which another party could be held liable, or are covered under automobile no-fault insurance; and
- If you have other health insurance or coverage based upon a family member's current employment.
You may access a sample Medicare Secondary Claim Development questionnaire in the Downloads section at the bottom of this page. Note that the questionnaire you receive may appear slightly different depending on the reason you are entitled to Medicare. If assistance is needed in completing the questionnaire, the BCRC should be contacted. For BCRC contact information, please click the Contacts link in the Related Links section below.
FAQs
Usually, your employer's plan is primary. If you also are covered by your spouse's plan, that plan is usually secondary. There are other rules for many other situations. A special case may come up if you have both medical and dental insurance, and you have a procedure such as oral surgery.
How do you determine which insurance is primary? ›
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.
Is it worth having two health insurances? ›
There are benefits and drawbacks to having two health insurance plans. A secondary health insurance plan may be able to cover expenses that your primary plan doesn't. Your overall out-of-pocket costs may be reduced if the plans complement each other to help limit your individual responsibilities.
What is the purpose of section 111 reporting? ›
The purpose of Section 111 reporting is to enable Medicare to correctly pay for the health insurance benefits of Medicare beneficiaries by determining primary versus secondary payer responsibility. Section 111 authorizes CMS and GHP RREs to electronically exchange health insurance benefit entitlement information.
What happens when I have two health insurance policies? ›
Understanding primary and secondary insurance
You may owe cost sharing. Secondary insurance: once your primary insurance has paid its share, the remaining bill goes to your “secondary” insurance, if you have more than one health plan. Your secondary insurance may cover part or all of the remaining cost.
How does double health insurance work? ›
The advantage of having two health insurance plans is that they cover more medical costs and out-of-pocket expenses than a single plan. The primary insurance plan may cover what the second plan does not. The secondary health insurance plan may cover the copays, deductibles and coinsurance of the first plan.
How do primary and secondary insurances work together? ›
The primary plan pays first. The secondary plan may also pay, depending on what it covers and how much the primary plan pays. Even if you receive benefits from both plans, they may not cover all your costs. The combined benefits should never be more than the cost of your care.
Does it matter which insurance is primary or secondary? ›
Your primary plan initially picks up coverage costs, followed by the secondary plan. You might still owe out-of-pocket costs at the end. Health plans have coordination of benefits, which is a process that decides which plan is primary and which one pays second.
How do primary and secondary insurance work? ›
What it means to pay primary/secondary. The insurance that pays first (primary payer) pays up to the limits of its coverage. The one that pays second (secondary payer) only pays if there are costs the primary insurer didn't cover. The secondary payer (which may be Medicare) may not pay all the remaining costs.
What is the difference between a PPO and a HMO? ›
HMOs don't offer coverage for care from out-of-network healthcare providers. The only exception is for true medical emergencies. With a PPO, you have the flexibility to visit providers outside of your network. However, visiting an out-of-network provider will include a higher fee and a separate deductible.
Primary insurance pays first for your medical bills. Secondary insurance pays after your primary insurance. Usually, secondary insurance pays some or all of the costs left after the primary insurer has paid (e.g., deductibles, copayments, coinsurances).
Is it better to have joint or separate health insurance? ›
There are a few things to consider when making this decision. First, what type of coverage does each of you need? If one of you has a chronic illness or condition that requires regular treatment, it may make more sense to have a separate plan that covers those costs.
What does CMS stand for in healthcare? ›
The Centers for Medicare and Medicaid Services (CMS) provides health coverage to more than 100 million people through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.
How to avoid a Medicare set aside? ›
Can You Avoid a Medicare Set-Aside? You can bypass the MSA, but remember, if the settlement involves future medical expenses and potential Medicare benefits, we recommend against it. Federal law under MSP prevents any attempts to shift costs to Medicare.
What is mmsea reporting? ›
Pursuant to Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA Section 111), the new mandatory reporting requirements apply to Group Health Plans that provide coverage to Medicare beneficiaries, as well as to liability insurance providers (including self-insurance), no-fault insurance, and ...
What is the process of determining which company is primary and which is secondary? ›
If you have dual coverage, health insurance companies will determine which of them are the primary and secondary payers through a process called coordination of benefits, or COB. This helps carriers and participants get on the same page when there are two types of insurance plans.
What happens when a secondary insurance allows more than primary? ›
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.
