What is Medicare's Secondary Payer Program?

It’s not uncommon to have an insurance plan for everything, just in case. You can have a Medicare plan, a drug plan, and a dental, vision, and hearing plan. You also may have life insurance, long-term care, and more. It’s possible to have one that plan encompasses mutliple types of coverage, like a Medicare Advantage plan that covers prescription drugs, and dental, vision, and hearing services.

Sometimes, it’s possible to have multiple policies for a single coverage, with one becoming the primary payer and the other the secondary payer. With health care coverage as thorough as Medicare, many people stick with just Medicare, but you can have a second health plan alongside it. This is the Medicare Secondary Payer Program.

Facts and figures can be found in the Medicare Secondary Payer fact sheet or Medicare & Other Health Benefits: Your Guide to Who Pays First unless linked elsewhere.

Why is There a Medicare Secondary Payer Program?

In many ways, the Second Payer Program can benefit both the beneficiary and Medicare as a whole. For beneficiaries, it allows them to be enrolled in Medicare and another health insurance plan. Together, these can cover many of the health costs that you may encounter. In many cases like this, the primary coverage will pay for the services and equipment first, up to its standard limits. Whenever there’s a gap in that coverage or something isn’t covered in full, there’s an opportunity for the secondary payer to step in and cover some of the leftover costs. While you may still be left with some out-of-pocket costs after everything is said and done, there’s a good chance you’ll have less than you would have if you didn’t have the secondary payer.

In 2018 alone, the Medicare Secondary Payer program was estimated to have saved Medicare $8.5 billion.

In many cases, Medicare will act as a secondary payer, backing up the qualified coverage you already have. Not only does this shift responsibility to the primary payer, it can also save Medicare money. By allowing the primary plan to handle the finances first, Medicare is able to extend the longevity of the Medicare trust funds. In 2018 alone, the Medicare Secondary Payer program was estimated to have saved Medicare $8.5 billion. There are circumstances where Medicare is the primary payer, though we’ll touch on these later.

How Using a Secondary Payer Work?

The coordination of your benefits is one of the most important aspects of primary and secondary payers and making sure you get your correct coverage. You can’t assume your primary or secondary payer knows about the other automatically. Instead, you should take the initiative and inform both insurers and your health care providers of your policies. Once you’ve begun the coordination effort, you should read your plan’s coordination of benefits rules, which lays out how interactions between primary and secondary payers (or more) will occur. In some cases, you may be responsible for sharing a claim with Medicare.

BCRC works with Medicare to manage multiple payer situations and assist beneficiaries with organizing and making sense of their benefits.

Luckily, you aren’t alone in coordinating your benefits. One place you can turn to for guidance is the Benefits Coordination & Recovery Center (BCRC). This resource works with Medicare to manage multiple payer situations and assist beneficiaries with organizing and making sense of their benefits. If you do call the BCRC, make sure you have your Medicare card on hand, since they’ll need information like your Medicare number, which parts of Medicare you have, and when you were first eligible for Medicare. You can call them toll-free at 1-855-798-2627, while TTY callers can use the number 1-855-797-2627.

What Determines the Secondary Payer?

There are many factors that determine which insurance is the primary payer and which is the secondary payer. We’ve provided some common examples in the table below. We encourage you to read the two resources we used (shared above) for a more exhaustive list, though even these admit they don’t have all the examples. For this reason, we suggest that you work with your insurance plans, a licensed insurance professional, or the BCRC when coordinating your coverage.

Coverage Qualifications	Enrollment Conditions	Primary Coverage Provider
Age 65+ with GHP	Employer with >20 employees	Medicare
Age 65+ with GHP	Employer with <20 employees	GHP
Age 65+ with Employer Retirement GHP	Isn’t working	Medicare
Under 65, but Qualifies Through Disability with GHP	Employer with >100 employees	Medicare
Under 65, but Qualifies Through Disability with GHP	Employer with <100 employees	GHP
Medicare-Eligible with COBRA Coverage	Has Medicare and COBRA Coverage	Medicare
Medicare-Eligible with Dual-Eligibility with Medicaid	Has both Medicare and Medicaid Coverage	Medicare
Eligible for Medicare and TRICARE	Active-Duty Military Member	TRICARE
Eligible for Medicare and TRICARE	Inactive Military Member Receiving Care at Military Hospital or Federal Provider	TRICARE
Eligible for Medicare and TRICARE	Inactive Military Member Receiving Care at Civilian Facility	Medicare

GHP — Group Health Plan, which can include employer-funded coverage through your work or a spouse’s work, etc. COBRA — Consolidated Omnibus Budget Reconciliation Act of 1985 allows employees to maintain health insurance after leaving employment under certain conditions and for a certain amount of time.

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As you can see, the specifics of primary responsibility can get fairly granular, with factors as small as the type of health care facility deciding which coverage takes over first. We didn’t even get into details like networks or if the primary payer denies a claim. While the topic of secondary payers can be complicated, working with a professional or the BCRC can help you navigate the ins and outs so you can have additional coverage to help with health care costs.