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
Knowing about other policies helps insurers determine the policyholder's financial exposure and ensure that the coverage amount is appropriate.
How to determine which insurance is primary and secondary? ›
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.
Can you argue with health insurance? ›
Your right to appeal
You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process. External review: You have the right to take your appeal to an independent third party for review. This is called an external review.
How does secondary insurance work with deductibles? ›
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 worth it to have two health insurances? ›
While the phrase “two are better than one” applies to many situations, two health insurance plans can be a burden, depending on your situation. However, two plans can also help you access needed care and save money on annual medical costs.
What is an example of coordination of benefits in healthcare? ›
For example, suppose you visit your doctor and get billed $250 for the appointment. Your primary health plan may cover the majority of the bill. Let's say, for example, that's $200. Then your secondary plan would pay the remaining $50.
What happens if a patient has coverage under two insurance plans? ›
Having two health insurance policies doesn't mean you'll be covered twice by both plans. For example, if you sprain your ankle and go to the doctor, your visit isn't going to be reimbursed multiple times. Both plans may cover some of the expenses, but the combined benefits won't surpass the total cost of your visit.
How does billing work with two insurances? ›
The way it works is that one plan is designated as primary insurance and the other as secondary. A claim goes first to the primary insurance plan, which pays medical bills the way it normally would. It is only after the primary insurer pays the claim that it gets submitted to the secondary plan.
Can I have Medicare and employer coverage at the same time? ›
Can I combine employer health insurance with Medicare? If you or your spouse are working and covered through an employer, you can also decide to keep this coverage and enroll in Original Medicare, Part A and/or Part B to get additional health coverage.
Which health insurance company denies the most claims? ›
Claim denial rates by insurance company
| Company | Claim denials |
|---|
| UnitedHealthcare | 32% |
| Anthem | 23% |
| Aetna | 20% |
| CareSource | 20% |
1 more rowMay 15, 2024
If you are not satisfied with your health insurer's review process or decision, call the California Department of Insurance (CDI). You may be able to file a complaint with CDI or another government agency. If your policy is regulated by CDI, you can file a complaint at any time.
Why would a health insurance company refuse to insure you? ›
If you are unemployed, in part-time work or retired, or if your income is low, you are more likely to be denied health insurance, as your insurer may consider you to be at risk of being unable to afford your premiums.
Which insurance is primary when you have two? ›
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.
How do copays work when you have two insurances? ›
In most cases their secondary policy will pick up the copay left from the primary insurance. There are some cases where the secondary policy also has a copay and those patients may end up with a copay applied after both insurances process the claim.
Why do car insurance companies ask if you are currently insured? ›
A lapse (or several lapses) in car insurance coverage can lead to higher premiums, so the longer you've been consecutively insured, the less you can expect to pay for your car insurance policy, in general. When you get your Esurance quote, we ask you how long you've been continuously insured.
What happens if an insured has coverage through two different insurance companies? ›
Your two insurance companies will need to agree with one another about who will cover what part of the claim, which can dramatically extend the amount of time it takes for you to receive a settlement. Your premium costs from both insurers will rise after a claim.
Should I have all my insurance with one company? ›
Whether it's personal assets or professional assets, you have a lot to protect. But that doesn't mean you need to use multiple insurers to do it. In fact, having your home, auto and business policies with one company can help you save – time, money and a whole lot of trouble.
Why would an insurance company refuse to insure you? ›
Car insurance companies are more likely to deny insurance to people they believe are more likely to file a claim. Insurance companies frequently deny coverage if the applicant has a recent history of accidents, a series of minor traffic tickets or a serious infraction such as a DUI.
