Quick Guide to Which Insurance Plan Pays First
In Triage Health's free Quick Guide to Which Insurance Plan Pays First, you'll learn how different types of plans work together, including the Federal Employees Health Benefits (FEHB) Program, Medicaid, Medicare, Veterans Administration (VA) Health Benefits, and TRICARE.
If you have more than one health insurance plan, it is important to understand how your plans work together to pay for your health care. This is called “coordination of benefits” (COB). Generally, one plan is going to pay first (the “primary payer”), and the second plan may pay an additional amount if the primary payer did not cover the entire bill. Some people may have coverage from three health insurance plans, in which case there may be a third or “tertiary payer.” This Quick Guide provides an overview of how different plans may work together to pay for your health care.
An example:
Maria and William are a married couple with two young children, living in New York. Maria has an individual health insurance plan through her employer. William has health insurance through his employer also, but William has a family plan that covers William, Maria, and their children. Maria’s plan through her own employer is her primary payer and the plan through her husband’s employer is her secondary payer. Maria has surgery and the hospital sends a bill to both insurance companies. The insurance plan through Maria’s employer pays its share of the bill first. Her husband’s plan pays the remainder of the bill.
COB rules vary by state and by insurer. If you are covered by more than one health insurance plan, it is important to:
- Understand which of your plans is primary and which is secondary. You can look at the Evidence of Coverage from each plan to see if there is a COB section. If you can’t find the information, you can contact each of your insurance companies and ask whether they are your primary or secondary payer.
- Let each of your health insurance plans know that you have coverage besides theirs; tell them the name of the other insurance plan and how you have it (e.g., through a spouse’s employer or through your military service.)
- Let each of your health care providers know about all of the insurance plans that you have.
Certain types of health insurance have specific COB rules.
Federal Employees Health Benefits (FEHB) Program
The FEHB Program provides employer-sponsored group health insurance for federal employees, retirees, former employees, family members, and former spouses. The FEHB has COB rules for people who have FEHB and another health insurance plan. For details, visit opm.gov. To ask questions, current employees and family members can contact their employing agency’s Human Resources Office or their health plan. Retirees can call 1-888-767-6738.
Medicaid
Medicaid has COB rules for when someone has Medicaid and another type of health insurance. Medicaid usually pays for a claim only after all other insurance(s) have paid their share of the claim first. If you have health insurance other than Medicaid, that health insurance is generally your primary payer. For more details, visit Medicaid.gov.
Medicare
Medicare has COB rules when someone has Medicare and another type of health insurance. Sometimes there are different COB rules if someone is eligible for Medicare because of their age, or because they have a disability. For example:
| What insurances does the person have? | Which insurance is primary? | Which insurance is secondary? |
|---|---|---|
| Medicare (due to being age 65+) & Employer-sponsored coverage | Employer-sponsored coverage (if employer has at least 20 employees) | Medicare |
| Medicare (if employer has fewer than 20 employees) | Employer-sponsored coverage | |
| Medicare (due to disability/ under age 65) & Employer-sponsored coverage | Employer-sponsored coverage (if employer has at least 100 employees) | Medicare |
| Medicare (if employer has fewer than 100 employees) | Employer-sponsored coverage | |
| Medicare & COBRA | Medicare (if you had Medicare prior to becoming eligible for COBRA) | COBRA |
| Medicare (if you had COBRA and then became eligible for Medicare) | None — COBRA will generally stop once eligible for Medicare | |
| Original Medicare & Medicare Supplement (Medigap) | Medicare | Medigap |
| Medicare & Medicaid | Medicare | Medicaid |
| Medicare & VA Benefits | Medicare & VA Benefits do not generally work together. If you receive services in a VA facility, those services should be covered by VA Benefits. If you receive services from a Medicare provider, Medicare should cover those services | Usually none |
| Medicare & TRICARE | Medicare (if not on active duty) | TRICARE for Life |
For questions, contact the Benefits Coordination & Recovery Center at 1-855-798-2627 or Medicare.gov.
Veterans Administration (VA) Health Benefits
Generally, VA health care benefits only cover services someone receives at a VA facility or from a VA provider. Veterans can have different benefits packages. If a Veteran has VA coverage and other health insurance, they are required to let the VA know and should ask the VA about what the VA will pay and what the other insurance will pay for health care and prescription drugs. To learn more, visit this website on VA health care and other insurance, or call the VA Health benefits hotline at 877-222-VETS (8387).
TRICARE
TRICARE is health insurance for active-duty service members and their family members, National Guard and Reserve members and their family members, retirees and their family members, survivors, and certain former spouses. There are several TRICARE programs, including TRICARE for Life. TRICARE pays after all other health insurance except Medicaid, TRICARE supplements, State Victims of Crime Compensation Programs, and other federal programs (e.g., Indian Health Service). If you have Medicare and TRICARE for Life, Medicare pays first. For details about TRICARE for Life, visit this website or call 1-866-773-0404.
Learn More
For more information, see our Health Insurance Topics Page, and our Health Insurance and Navigating Health Insurance Cancer Finances modules.
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Last reviewed for updates: 01/2022
Disclaimer: This handout is intended to provide general information on the topics presented. It is provided with the understanding that Triage Cancer is not engaged in rendering any legal, medical, or professional services by its publication or distribution. Although this content was reviewed by a professional, it should not be used as a substitute for professional services. © Triage Cancer 2023