Defining Medicare primary, secondary payers
News and Views from Rita
I have been asked what the difference is between a primary and secondary payer in Medicare.
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 uncovered costs. Remember, Medicare usually pays only 80 percent of the cost of the medical procedure.
If your employer insurance is the secondary payer, you may need to enroll in Medicare Part B before your insurance will pay or you need to have Medigap insurance, which is a supplemental insurance to Medicare.
Note: If you are working past age 65 and have insurance through your active employment or your spouse’s active work, then that is typically the “primary” payer. If you have Medicare, it would be the secondary. But if the number of employees in the group is less than 20, then Medicare is the “primary” and the employee coverage may be secondary.
Paying “first” means paying the whole bill up to the limits of the coverage. It doesn’t always mean the primary payer pays first in time. If the insurance company doesn’t pay the claim promptly (usually within 120 days), your doctor or other provider may bill Medicare.
Medicare may make a conditional payment to pay the bill, and then later recover any payments the primary payer should’ve made.
A conditional payment is a payment Medicare makes for services another payer may be responsible for. Medicare makes this conditional payment so you won’t have to use your own money to pay the bill. The payment is “conditional” because it must be repaid to Medicare when a settlement, judgment, award or other payment is made.
That is, if Medicare makes a conditional payment for an item or service, and you get a settlement, judgment, award, or other payment for that item or service from an insurance company later, the conditional payment must be repaid to Medicare.
Be sure to tell your doctor and other healthcare providers if you have coverage (other insurance) in addition to Medicare. This will help them send your bills to the correct payer to avoid delays.
If you have questions about who pays first, or if your insurance changes, call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627. TTY users should call 1-855-797-2627 or call 1-800-MEDICARE about coordination of benefits.
If you have questions about Medigap, please contact our office at 907-276-1059 in Anchorage or toll-free statewide at 1-800-478-276-1059 and we will send you a brief summary of all the Medigap policies and a list (including 800 telephone numbers) of all the insurance companies in Alaska that handle the policies.
Rita Hatch is an Older Persons Action Group board member and volunteers for OPAG’s Medicare assistance program. Call her in Anchorage at 276-1059 or toll-free statewide at 1-800-478-1059. Her email address is firstname.lastname@example.org.