Coordinating benefits and recovery in Medicare

Medical News Today

12-05-2025

Coordination of benefits rules determines which insurer pays first when someone has multiple health plans, including Medicare. Medicare can challenge this process through recovery.
Benefit coordination is integral to the Medicare Secondary Payer Program. This assists Medicare in identifying situations in which the insurer should not be the primary payer for claims.
The Benefits Coordination & Recovery Center (BCRC) and the Commercial Repayment Center (CRC) handle various components of the coordination and recovery process. This article gives further insight into how Medicare coordinates and recovers benefits. How does the coordination of benefits work with Medicare?
Medicare typically acts as the primary payer when a person has insurance with Medicare and another health insurance plan, such as a group health plan of under 20 employees or Continuation of Health Coverage (COBRA).
However, in other situations, Medicare becomes the secondary payer. These circumstances include when:
a person's employer has 20 or more employees
the person has a disability and has coverage by a plan from an employer with 100 or more employees
an individual is living with end stage renal disease (ESRD)
Additionally, Medicare might pay second (secondary payer) if a person is involved in an accident and covered by no-fault or liability insurance or if workers' compensation covers them. How long is the coordination period for Medicare?
The coordination of benefits period can last as long as 30 months. What is CMS's Benefits Coordination and Recovery Center?
The Centers for Medicare & Medicaid Services (CMS) uses the BCRC to determine whether a person has health insurance coverage other than Medicare.
Occasionally, after Medicare pays a claim, the BCRC may discover that a person's group health plan should have been the primary payer. In such instances, the CRC recovers the funds from the employer and the group health plan.
Additionally, the CRC is responsible for recovering incorrect payments when a person is self-insured or if liability insurance, no-fault insurance (personal injury protection insurance), or a workers' compensation provider is involved. How do I fix Medicare's coordination of benefits?
Understanding the coordination of benefits and recovery process can be challenging. It is important to understand that when a person has two health insurance policies, the primary insurer will cover expenses up to its coverage limit first. If any costs remain, the secondary payer will step in. However, the secondary payer, such as Medicare, might not cover every remaining expense.
On the other hand, there may be instances where Medicare is the primary insurance, and an employer's plan is the secondary. In these cases, the insured person may need to enroll in Original Medicare's Part B plan instead of an equivalent Medicare Advantage (Part C) plan for their employer's insurance to help with their costs.
Some other factors to consider include:
If a person is dually enrolled in Medicaid and Medicare, Medicaid will always be the secondary payer.
If an individual is in the military and enrolled in Medicare, TRICARE is the primary payer for Medicare services.
If the other insurance is part of a multiple-employer plan, only one of these plans needs to meet the employee count requirement for the group health plan to be the primary payer. Who should a person call if they have a Medicare coordination of benefits issue?
It is crucial to inform the CMS if changes occur in a person's insurance coverage outside of Medicare. In addition, if someone is uncertain which insurance provider should be the primary payer, they can review the insurance policy or coverage details of their other plan.
They can also contact their employer, union benefits administrator, or the BCRC at 855-798-2627 (TTY 1-855-797-2627).
If a person believes there an error has occurred in how Medicare and their other insurer have allocated coverage, they can file an appeal. They can find out more about the appeal process on Medicare.gov.
The Medicare Secondary Payer program helps Medicare identify instances where it should not be the main payer for medical claims.
The Benefits Coordination & Recovery Center (BCRC) and the Commercial Repayment Center (CRC) collaborate to establish the correct payment order between a person's two insurers and to recover funds if payments were managed incorrectly.
Understanding this process can help inform people how their medical expenses are covered when they have both Medicare and private insurance.
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