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What Does “Primary Insurance Status” Mean?

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Medicare beneficiaries may have other insurance coverage in addition to their Medicare plan. When an insurance company has “primary insurance status,” it means that that insurer will pay on the beneficiary’s health-care claims first, while Medicare pays second. Please note that regardless of whether Medicare or the other insurance pays first, you will still be responsible for cost sharing associated with each. This refers to out-of-pocket costs paid by the beneficiary and may include any deductibles, copayments, and/or coinsurance costs required for covered services, both for Medicare and your other insurance.

Other types of insurance you may have include:

  • Auto insurance
  • Black lung benefits
  • Group health plans under certain conditions*
  • Homeowner’s insurance
  • Workers’ compensation
  • COBRA
  • Veterans’ benefits
  • TRICARE

If you do not have any of the above types of insurance and do not have another type of insurance listed as the primary payer, then Medicare is your primary insurance. In this scenario, your doctor or health provider will generally submit a claim to Medicare first before billing you for your share. You will still be responsible for paying the Medicare deductible, coinsurance, and copayment amounts for covered services.

If a beneficiary’s other insurance has primary insurance status but does not pay first in time, Medicare may make a conditional payment and then recover the payments from the primary insurer later.

*A group health plan may be the primary payer under some situations if specific conditions are met. For example, one situation where the group plan would pay first if a) the beneficiary has end-stage renal disease (ESRD) and is covered under a group plan, and b) the beneficiary is in the first 30 months of Medicare eligibility or entitlement. This isn’t the only situation where your group health plan may pay first. For a list of common situations where Medicare might be a primary or secondary payer, see this publication, “Your Guide to Who Pays First.” If you have questions about how Medicare works with other insurance you may have, contact the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627; TTY users should call 1-855-797-2627.

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