If you have access to Medicare, you may have additional types of insurance that pay for medical treatment. “Primary insurance status” means that the other insurance is responsible for paying its share of the charges first, then Medicare will pick up its portion of the bill if there is anything left.
What Is Primary Insurance Status for Medicare?
Primary insurance status is how multiple insurance policies determine who pays first when you also have Medicare. Any health insurance policy that you have as a member, subscriber, or employee will generally have primary insurance status.
These types of insurance can include, but are not limited to the following:
- Auto insurance
- Black lung benefits
- Group health plans under certain conditions
- Homeowner’s insurance
- Veterans’ benefits
- Workers’ compensation
If you do not have other health insurance coverage, Medicare will be your primary payor and will be charged first. However, with the other insurance policies listed above, Medicare will likely be the secondary payor.
This means that your other health insurance will be billed and paid first. After benefits are exhausted for the claim, Medicare will then be billed and pay its portion of the remaining balance.
You are responsible for any of the cost-sharing portions of both policies. Cost-sharing includes:
- Coinsurance (percentage of the bill, such as 20%)
- Copay (a fixed amount of the bill, such as $25)
- Deductible (the amount you pay before the insurance policy covers anything)
How Do You Know if Your Insurance Is Primary or Secondary?
You can read Medicare’s guide that explains whether your Medicare policy pays first or second. However, you will not usually have to handle this.
Instead, your medical provider and their claims department should manage this coordination of benefits. If Medicare is not primary and your primary insurance does not pay the claim in a timely manner, Medicare will pay the claim provisionally and then seek reimbursement from the primary insurer.
How Do You Set Up Primary Insurance?
Medicare will send you a secondary claim development questionnaire to gather other insurance information. You should complete this questionnaire in a timely manner. If your insurance coverage changes, you’ll want to reach out to Medicare’s Benefits Coordination and Recovery Center (BCRC) at (855) 798-2627. The BCRC is open Monday through Friday 8 a.m.to 8 p.m. Eastern time.
You’ll also want to keep your medical providers aware of any insurance you may have besides Medicare.
Can You Have Other Health Insurance as Primary Insurance With Medicare?
Yes, you can have other health insurance as primary with Medicare, but only if it follows Medicare coordination of benefit rules. For example, you cannot have a Health Insurance Marketplace plan and Medicare at the same time.
You can, however, have an employer (or spouse employer) plan and Medicare at the same time. The coordination of benefits depends on the size of your employer.
Employers with more than 20 employees or are part of a multiple employer group health plan will always have the employer plan pay first. Employers that have less than 20 employees and aren’t a part of a multiple employer group health plan will have Medicare pay first.
To verify who the primary payor is, contact your employer’s benefit coordinator.
Learn More From Our Sources
- CMS | Reporting Other Health Insurance | Last accessed October 2022
- Medicare | How Original Medicare Works | Last accessed October 2022
- Medicare | How to Get Prescription Drug Coverage | Last accessed October 2022
- Medicare | Medicare Advantage Plans | Last accessed October 2022
- Medicare | What’s Medicare Supplement Insurance (Medigap)? | Last accessed October 2022
- Medicare | Your guide to who pays first. | Last accessed October 2022