Medicaid Secondary

January 1, 2005

If a patient has Medicaid and another (commercial) insurance, we assume the commercial insurance is primary and that Medicaid is secondary. Medicaid is usually aware of the other insurance. We check our state Medicaid eligibility online, and if another insurance is in its system as primary it tells us so in the printout. If Medicaid has never been informed of the other policy, and the patient wants us to bill Medicaid instead of his insurance, is that considered fraud?

Question: If a patient has Medicaid and another (commercial) insurance, we assume the commercial insurance is primary and that Medicaid is secondary. Medicaid is usually aware of the other insurance. We check our state Medicaid eligibility online, and if another insurance is in its system as primary it tells us so in the printout. If Medicaid has never been informed of the other policy, and the patient wants us to bill Medicaid instead of his insurance, is that considered fraud?

Answer: According to Medicaid in your state, "If a member has health insurance that covers a provided service, the insurance is the primary payer. (Medicaid) does not pay for services that the member's health insurance is legally obligated to pay."

This does not explicitly call it fraud, but, indeed, why should the state pay for what the beneficiary already has paid for in the form of premiums?

You should bill the primary insurance first.

You certainly can contact your state Medicaid administrator for the legal implications in more depth.