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Primary Vs. Secondary Health Insurance

While most people with health insurance are only covered by one health insurance plan, some choose to have coverage through two group policies. This generally occurs when both spouses work and participate in their respective employers' plans, and both elect spousal benefits. When you're covered by two group health insurance policies, there are a set of a rules to determine which one should pay first.

  1. Coordination of Benefits

    • To address the issue of double medical coverage, states have adopted a specific set of guidelines to determine which health insurance plan pays first. The goal is to ensure that the entire bill for medical services gets paid in full, without overpaying or underpaying any provider.

    Primary Carrier

    • The plan that pays first is the Primary Carrier. Your employer's group health insurance policy is always considered the primary plan, even if your spouse's plan is more comprehensive or has better benefits. Invoices for your medical treatment are submitted to your employer's health insurance carrier first, and payment is made up to that policy's limits.

    Secondary Carrier

    • Your spouse's health insurance plan is the Secondary Carrier. Any remaining balance after the primary plan pays gets submitted to your spouse's company. That plan then pays the rest of the bill, up to the maximum for its own benefits.

    Children

    • If you and your spouse are both covered by one another's group health insurance plans, and you also both have your children listed as covered dependents, your birthdays will determine which plan is primary. This guideline is called the "Birthday Rule" and the plan covering the spouse whose birthday arrives earlier in the year is the primary carrier.

    Medicare

    • If you're covered by Medicare, the size of your employer's company determines whether Medicare or the group policy is the primary carrier. Plans covering small companies with less than 20 workers become the secondary carriers, while plans covering employers with more than 20 workers are primary.

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