What is the Medicare Program's Secondary Payer Program?

It’s not uncommon to have different types of insurance plans with different focuses. You can have a Medicare insurance plan, a drug plan, and a stand-alone dental, vision, and/or hearing plan. You also may have life insurance, long-term care coverage, and more. It’s possible to have one plan that encompasses and covers multiple types of coverages and benefits, like a Medicare Advantage plan.

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 insurance as a whole. For beneficiaries, it allows them to be enrolled in the Medicare program 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 the Medicare program $8.5 billion.

In many cases, Medicare insurance 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 the Medicare program money. By allowing the primary plan to handle the finances first, the Medicare program is able to extend the longevity of the Medicare trust funds. In 2018 alone, the Medicare Secondary Payer program was estimated to have saved the Medicare program $8.5 billion. There are circumstances where Medicare insurance 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 insurance.

BCRC works with Medicare insurance 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 insurance 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 insurance card on hand, since they’ll need information like your Medicare insurance number, which parts of the Medicare program you have, and when you were first eligible for the Medicare program. 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.

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.