As first note, let us understand Medicare insurance.
Medicare is the federal government program that provides health care coverage for the following people,
- People who are 65 or older
- Certain younger people with disabilities
- People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)
The program is funded US Government.
In most cases, patient have only one insurance (called as primary insurance) and normally the claim is sent to primary insurance via CMS 1500 Form or EDI. After primary insurance process, if there is balance left in the claim, then it is collected from the patient.
In some cases, the patient may more than one insurance policy and billing office(Front desk or reception) in the doctor office responsibility to identify which needs to bill first and then second and so on.
What it means to primary/secondary insurance policy ?
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.
Here is some guideline how to identify the primary, secondary, etc if the patient has more than one insurance policies
1) If the patient is working and less than 65 years old and spouse is also working, if both are covered by their employer, they may both have family policies , so they are covered under each other employer plan. In this case, patient employer insurance would be primary and spouse employer insurance will be secondary.
2) If the patient is retired and 65 years old. Then federal Medicare coverage is available for him. If the patient spouse still working and having a family policy coverage by their employer, then spouse plan would be primary and medicare becomes secondary.
3) In the above case, if the patient is retired from military services and still covered by military insurance, then that would be third (Tertiary) insurance.
4) If the patient is still working and is also eligible for Medicare and has insurance through their employer, the employer insurance is primary and Medicare is secondary.
5) If the patient is covered by Medicare and have group health coverage from his former employer, then Medicare becomes primary and former employer insurance becomes secondary.
6) The following are the scenarios where Medicare is primary :
- An individual who is working for an employer with twenty employees or fewer
- An individual who is covered by another policy that is not a group policy
- An individual who is enrolled in Part B but not Part A of the Medicare program
- An individual who must pay premiums to receive Part A coverage
- An individual who is retired and receiving coverage under a previous employer’s group policy
7) Medicare (and private insurance) is always the secondary payer when treatment is for an accident-related claim, whether automobile, no-fault (injuries that occur on private property, regardless of who is at fault), or liability (injuries that occur on private property when a party is held responsible)
These are not hard-and-fast rules though, it is better to double check with all insurance companies to see exactly which is primary and secondary.
