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Coordination of benefits (COB) determines which health plan pays first when more than one plan may cover the same medical claim. The primary plan processes the claim first; a secondary plan may then consider eligible costs left over under its own rules. That does not mean the secondary plan will pay every remaining charge.
How coordination of benefits works
HealthCare.gov defines coordination of benefits as “A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.” The plan that pays first is called primary; the other plan is secondary.
CMS explains that the primary payer pays what it owes first and then sends the rest to the secondary payer. As CMS puts it, “The primary payer pays up to the limits of its coverage.” The secondary plan then evaluates the claim under its own coverage, exclusions, cost-sharing, and coordination terms. It may pay some eligible costs the primary plan did not cover, but a balance can remain the member’s responsibility.
COB is about allocating payment for a covered expense—not choosing whichever plan has the lower deductible, nor guaranteeing that the combined plans will reimburse every billed amount. See HealthCare.gov’s COB definition and CMS’s explanation of other health insurance.
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When Medicare is one of the plans
There is no single rule that makes Medicare always primary or always secondary. Federal Medicare Secondary Payer rules use the person’s circumstances, including age, disability, end-stage renal disease (ESRD), whether coverage is tied to current employment, employer size, and the type of care. These are general examples from CMS, not a personalized determination.
Age 65 or older with coverage through current employment
For a person age 65 or older who has a group health plan through current employment—either their own or a spouse’s—CMS says the employer-size threshold matters. A plan from an employer with fewer than 20 employees generally pays after Medicare. A plan from an employer with 20 or more employees, including a qualifying multi-employer group, generally pays before Medicare.
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Disability and current-employment coverage
For a person with a disability and qualifying group health coverage through current employment, CMS identifies a 100-or-more-employee threshold for the group plan to pay before Medicare. Confirm that the coverage and employment meet the applicable rule rather than applying the age-65 example.
ESRD, COBRA, and retiree coverage
ESRD and COBRA have rules of their own, including a 30-month coordination period for ESRD cases. They should not be treated as ordinary working-aged cases. CMS also gives retiree coverage as an example that is generally secondary to Medicare for an individual age 65 or older with an employer retirement plan.
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Accidents and work-related injuries
When care is related to an accident or situation covered by no-fault or liability insurance, that coverage pays before Medicare in the circumstances described by CMS. Workers’ compensation is primary for care related to a job-related illness or injury.
For the full set of Medicare payer-order examples, consult CMS’s Medicare Secondary Payer guidance. The relevant coverage category and facts must be established before deciding which plan is primary.
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How private plans coordinate—and where the birthday rule fits
For two private plans, the applicable state rules and the actual plan documents matter. A familiar provision for a child covered as a dependent on both parents’ plans is the birthday rule: the plan of the parent whose birthday falls earlier in the calendar year may be primary. It uses the month and day, not which parent is older. But that wording is not a universal rule for every state or policy.
The National Association of Insurance Commissioners’ coordination regulation is a model, not proof that every state adopted identical terms. Its model includes dependent-child ordering provisions and special handling where federal Medicare law sets the order. Before relying on the birthday rule, check the applicable state requirements and both plans’ coordination-of-benefits provisions. The model is available in the NAIC Coordination of Benefits Model Regulation.
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What to check to identify the primary plan
Gather the details that determine which rules apply before asking a plan to reprocess a claim or estimating what you will owe:
- Coverage type and relationship: Identify each plan and whether you are covered as the employee or subscriber, a spouse or dependent, or through retiree coverage.
- Employment status: For Medicare cases, establish whether the coverage comes from current or former employment and, when relevant, the employer’s size.
- Reason for the care: Note whether treatment is connected to an accident, liability or no-fault coverage, or a job-related injury or illness.
- State and plan terms: For private-plan coordination, confirm the applicable state rule and read both plans’ provisions.
What to do if you have Medicare and another plan
- Respond to CMS questionnaires. Return the Medicare Secondary Claim Development Questionnaire in a timely manner so CMS can establish whether other coverage may be responsible first.
- Report coverage and employment changes. Tell CMS’s Benefits Coordination & Recovery Center (BCRC) about changes involving your, your spouse’s, or a family member’s employment or insurance. Retirement, a job change, or an insurer change can affect claim handling.
- Tell your providers about every plan. Give doctors and other providers your Medicare information and details for any additional coverage so they can submit claims in the appropriate order.
- Ask the right organization about the issue. The BCRC collects and manages other-coverage information; it does not process claims. Medicare Administrative Contractors and other Medicare claims contractors process Medicare fee-for-service claims. For private coverage, contact the plan administrator or insurer and consult the plan documents.
CMS describes the distinction between coverage-information management and claims processing on its Coordination of Benefits page and its page on coordination and Medicare claims processing.
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