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Primary
and Secondary Health Insurance Claims
by Joyce Hedgepath
When
you are covered by more than one health insurance plan, who
pays first?
If the
patient is a child and both parents have health insurance
covering dependents, the answer can vary. However, most
insurers go by the birthday rule. The plan of
the parent whose birthday comes first in the calendar year
is usually primary for all children. For example, if the
father's birthday is on November 3 and the mother's is on
March 30, March comes before November in the calendar year,
so the mother's plan is primary. If the parents are
divorced, the terms of the divorce decree may determine
which parent's insurer is primary. If there is any doubt as
to which policy is primary, call the plan administrator for
clarification.
If a
person is covered by plans from two employers, the plan with
the earliest effective date is usually primary. Check with
the plan administrator to be sure.
For
those who have Medicare coverage, in
certain situations, Medicare may be the secondary payer. For
example,
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Patients with end stage
renal disease (group health plan pays first for 30 months)
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Claims related to black
lung
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Patients over 65 covered
by an employer group health plan (when there are more than
20 employees)
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Patients under 65 with
Medicare based on a disability covered by an employer
group health plan (when there are more than 100 employees)
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Patients with veterans
benefits can choose which benefits they wish to use
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Accident or work-related
illness or injury covered by workers' compensation |
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Claims for which no-fault
or liability insurance pays first.
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For
more information, call the Social Security Administration or
the Health Care Financing Administration for a copy of its
free pamphlet, "Medicare and Other Health Benefits-Who Pays
First". |
