Orlando Harmon
It is possible to have both private insurance and Medicare at the same time. When you have both, a process called coordination of benefits determines which insurance provider pays first. This provider is called the primary payer. The primary payer pays up to the limits of its coverage, after which the rest of the balance is sent to the secondary payer. The secondary payer then pays for costs that the primary payer does not cover. Medicare may be the primary payer, or it may be the secondary payer, depending on the type of private insurance you have and your individual situation.
| Characteristics | Values |
|---|---|
| Can you have both Medicare and private insurance? | Yes, it is possible to have both at the same time. |
| Who pays first? | The primary payer pays first, up to the limits of its coverage. The secondary payer then pays for any costs the primary payer doesn't cover. |
| How do you know which is the primary payer? | Check the policy details of both types of insurance. You can also contact the Benefits Coordination & Recovery Center. |
| What if the primary payer doesn't pay the claim promptly? | The provider may bill Medicare, which may make a conditional payment and then recover any payments the primary payer should have made. |
| What if I have a Medicare-approved Workers' Compensation Medicare Set-aside Arrangement? | Check with each of your types of insurance or coverage to get information about who pays first. |
| Can I join a Medicare drug plan if I have private insurance? | Yes, but you can't use both types of coverage for the same drug at the same time. |
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What You'll Learn
Medicare and private insurance coverage at the same time
It is possible to have both private insurance and Medicare at the same time. This can happen in several different situations. For example, you may have coverage through your employer or your spouse's employer, or you may be eligible for COBRA or TRICARE. When you have both types of insurance, a process called "coordination of benefits" determines which insurance provider pays first. This provider is called the "primary payer". The primary payer pays for any covered services until their coverage limit has been reached, after which the "secondary payer" covers the remaining costs, if there are any. Medicare may be the primary payer, or it may be the secondary payer, depending on the type of private insurance you have and your individual situation.
If you have questions about who pays first or if your coverage changes, it is important to contact your doctor and other healthcare providers, as well as Medicare's Benefits Coordination and Recovery Center. Medicare doesn't automatically know if you have other coverage, but your insurers must report to Medicare when they are the primary payer on your medical claims. You can also contact the Social Security Administration (SSA) to get more information on Medicare eligibility and enrollment. If you are a veteran, you can contact the Department of Veteran Affairs to learn more about your benefits and other insurance.
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Primary and secondary payers
When you have Medicare and another type of insurance, each type of coverage is called a "payer". The "primary payer" pays up to the limit of its coverage and then sends the rest of the balance to the "secondary payer". The secondary payer only pays if there are costs that the primary payer didn't cover. This order of payment is called "coordination of benefits".
Medicare is the primary payer in certain instances, provided several conditions are met. For example, if you are a working-age Medicare beneficiary (age 65 or older) and have an Employer Group Health Plan (GHP) through current employment or your spouse's current employment, and your employer has fewer than 20 employees, then Medicare pays primary and GHP pays secondary.
In 1980, Congress passed legislation that made Medicare the secondary payer to certain primary plans in an effort to shift costs from Medicare to the appropriate private sources of payment. The MSP provisions have protected Medicare Trust Funds by ensuring that Medicare does not pay for items and services that certain health insurance or coverage is primarily responsible for paying. The MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage.
When Medicare began in 1966, it was the primary payer for all claims except for those covered by Workers' Compensation, Federal Black Lung benefits, and Veteran’s Administration (VA) benefits. If you have a Medicare-approved Workers' Compensation Medicare Set-aside Arrangement amount, you should check with each of your types of insurance or coverage to get information about who pays first.
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Who pays first?
It is possible to have both private insurance and Medicare at the same time. When you have both, a process called "coordination of benefits" determines which insurance provider pays first. This provider is known as the "primary payer". The primary payer pays up to the limits of its coverage. The insurance that pays second (the "secondary payer") only pays if there are costs the primary insurance didn't cover.
The primary payer can depend on the type of private insurance you have and your individual situation. In some cases, Medicare may be the primary payer, while in others, it may be the secondary payer. For example, if you have non-tribal group health plan coverage through an employer with fewer than 20 employees, Medicare pays first, and the non-tribal group health plan pays second. Conversely, if you have a group health plan through an employer with more than 20 employees, your group health plan pays first, and Medicare pays second.
If you have questions about who pays first, or if your coverage changes, you can call Medicare’s Benefits Coordination & Recovery Center (BCRC) at 855-798-2627 (TTY: 855-797-2627).
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Coordination of benefits
If you have Medicare and another form of health insurance, such as a group health plan, retiree coverage, or Medicaid, each type of coverage is called a "payer". The order of payment, or "coordination of benefits", depends on which insurance is considered the "primary payer" and which is the "secondary payer". The primary payer pays up to the limits of its coverage, after which it sends the remaining balance to the secondary payer. If the secondary payer doesn't cover the remaining balance, the patient may be responsible for the remaining costs.
Medicare may be the primary or secondary payer depending on the situation. For example, if you have Medicare and your employer's insurance is the secondary payer, you'll need to join Medicare Part B before your employer's insurance will pay for Part B services. On the other hand, if you have Medicare and group health coverage, Medicare may be the secondary payer. In the case of an accident or injury that is an open ongoing responsibility medical case, liability or no-fault insurance must pay first.
It's important to note that Medicare doesn't automatically know if you have other coverage. Therefore, it's your responsibility to inform your doctor and other healthcare providers about any changes in your insurance or coverage. This will help them send your bills to the correct payer and avoid delays. If the insurance company doesn't pay the claim promptly (usually within 120 days), your doctor or provider may bill Medicare. In this case, Medicare may make a conditional payment to pay the bill and then recover any payments the primary payer should have made.
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Medicare as a secondary payer
Medicare Secondary Payer (MSP) is the term used when the Medicare program does not have primary payment responsibility. In other words, when another entity is responsible for paying before Medicare, that entity is the primary payer. The primary payer pays up to the limits of its coverage, then sends the remaining balance to the secondary payer. If the secondary payer doesn't cover the remaining balance, the patient may be responsible for the remaining costs.
When Medicare was established in 1966, it was the primary payer for all claims except those covered by Workers' Compensation, Federal Black Lung benefits, and Veteran's Administration (VA) benefits. In 1980, legislation was passed that made Medicare the secondary payer to certain primary plans, shifting costs from Medicare to the appropriate private sources of payment. The MSP provisions ensure that Medicare does not pay for items and services that certain health insurance or coverage is primarily responsible for paying.
Medicare is the primary payer for beneficiaries who are not covered by other types of health insurance or coverage. It can also be the primary payer in certain other instances, provided specific conditions are met. For example, if an individual is aged 65 or older and is covered by a Group Health Plan (GHP) through their current employment, Medicare is the primary payer.
If you have Medicare and other health insurance, it is important to know which is the primary payer and which is the secondary payer. You can contact your insurance provider or Medicare's Benefits Coordination & Recovery Center (BCRC) to clarify any questions about who pays first. Additionally, inform your doctor and other healthcare providers if you have coverage in addition to Medicare.
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Frequently asked questions
Yes, it is possible to have both private insurance and Medicare at the same time. This can happen if you have coverage through an employer or if you are on your spouse's private insurance.
The primary payer pays for any covered services until the coverage limit has been reached. The primary payer depends on the type of private insurance and your individual situation.
The secondary payer pays for costs that the primary payer doesn't cover. However, it may not cover all the costs.
The best way to check is to look at the policy details of both types of insurance. You can also contact the Benefits Coordination & Recovery Center at 1-855-798-2627.
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