Can You Have Medicaid as a Secondary Insurance?

Medicaid is a joint federal and state program that provides healthcare coverage to certain low-income individuals and families. It can indeed function as a secondary insurance, acting as a “payer of last resort” for eligible beneficiaries. This means that if an individual has other health insurance coverage, Medicaid typically pays after the primary insurer has processed the claim. While eligibility requirements and specific benefits can vary by state, the fundamental role of Medicaid as a secondary payer remains consistent across the country.

How Medicaid Coordinates with Other Coverage

When an individual has Medicaid alongside another health insurance plan, a process known as Coordination of Benefits (COB) determines which plan pays first. Federal law mandates that Medicaid is generally the “payer of last resort,” requiring all other available third-party resources to fulfill their payment obligations before Medicaid contributes. This mechanism ensures that the primary insurance always pays for covered services first.

After the primary insurer processes a claim and pays its share, the remaining balance, if any, is then submitted to Medicaid. Medicaid may cover various out-of-pocket costs such as deductibles, copayments, and coinsurance that the primary plan did not cover. It can also cover services that are not included in the primary plan’s benefits but are covered under Medicaid’s scope of services.

Medicaid’s Role with Specific Primary Insurances

Medicaid’s function as a secondary payer is particularly relevant for individuals covered by Medicare or private health insurance. For those with both Medicare and Medicaid, often referred to as “dually eligible,” Medicare acts as the primary payer for Medicare-covered services. Medicaid then steps in as the secondary payer, covering costs like Medicare premiums, deductibles, copayments, and coinsurance. This provides a safety net, similar to a Medigap policy, for low-income Medicare beneficiaries. Additionally, Medicaid can cover services that Medicare does not, such as certain long-term care, dental, or vision services.

When an individual has employer-sponsored health insurance or private health insurance in addition to Medicaid, the private plan is always the primary coverage. Medicaid will then cover out-of-pocket expenses, including deductibles and copayments, that the primary plan leaves unpaid. It may also pay for services that are not covered by the private plan but are included in Medicaid benefits. Individuals must inform Medicaid about any other insurance coverage to ensure proper coordination of benefits.

Understanding Your Coverage and Costs

When Medicaid functions as a secondary payer, individuals can expect their out-of-pocket expenses for medical care to be reduced or eliminated for covered services. Providers first submit claims to the primary insurer. Once the primary insurer processes the claim and makes its payment, the remaining balance is then forwarded to Medicaid for review and payment.

Medicaid covers remaining approved costs, such as deductibles, copayments, and coinsurance, that the primary insurer did not cover. It can also provide coverage for services the primary plan excludes but are medically necessary and fall within Medicaid’s benefit package. Patients bear minimal or no financial responsibility for services covered by both plans. Individuals should always ensure their providers accept both their primary insurance and Medicaid to avoid potential balance billing issues.