How to Answer the Medicare Secondary Payer Questionnaire

To answer the Medicare Secondary Payer Questionnaire correctly, work through its six parts in order and give your provider the details for every other insurer, employer plan, or injury claim that might cover your care: policy numbers, employer name and size, dates of injury, and claim numbers. Your answers decide whether Medicare pays your bill first or waits behind another insurer, so accuracy matters more than speed. You will see some version of these questions at every hospital admission, outpatient visit, or start of home health care, and for recurring outpatient services your provider must re-verify your answers at least every 90 days.¹

What You’re Actually Filling Out

The questionnaire is not a single government form. It’s a model set of screening questions from the Centers for Medicare & Medicaid Services (CMS) that providers adapt into their own intake paperwork, patient portals, or check-in kiosks.² Every provider that participates in Medicare has to collect this information before billing Medicare.¹ The point is to figure out whether Medicare is the primary payer or is second in line behind another insurer that has to pay first.

What to Have in Front of You Before You Start

The fastest way to get through the screening is to arrive with the right information already in hand. Gather these before you answer:

Every insurance card you hold, including employer group health plan cards, auto insurance, workers’ compensation documentation, and any supplemental or Medigap policy. The provider needs insurer names, policy numbers, and group numbers straight from the cards.³
Your employer’s or your spouse’s employer’s name, address, and approximate number of employees, if either of you is still working and covered by that plan. The headcount matters.
The date of any accident or work injury tied to this visit, plus the name, address, and claim number of the auto, no-fault, liability, or workers’ compensation insurer involved.
Your Medicare entitlement basis: age, disability, or end-stage renal disease (ESRD). If you’re not sure, check your Medicare card or call Social Security at 1-800-772-1213.

If your provider sends the questionnaire through a patient portal ahead of your visit, complete it there. That gives you time to look things up rather than guessing at the front desk.

The Six Parts and What Each One Asks

The CMS model questionnaire has six parts, answered in sequence.⁴ Your provider’s version may be reformatted, but the substance is the same.

Part 1: Government Programs and Work Injuries

Part 1 asks whether you receive Federal Black Lung benefits, whether a government research program will pay for your services, whether the VA has authorized and agreed to pay for care at that facility, and whether your condition is related to a work injury or illness. A “yes” to any of these means that program or insurer pays first for the related services. For a workers’ compensation claim, you’ll need the date of injury, the plan’s name and address, the policy or ID number, and your employer’s name and address.⁴

One caution on the VA question: answer “yes” only if the VA has specifically authorized and agreed to pay for the care at that non-VA facility. VA health care and Medicare otherwise operate on separate tracks, and the VA does not bill Medicare.⁵

Part 2: Accident-Related Injuries

If your visit involves a non-work accident, Part 2 asks whether a car was involved (which brings in no-fault auto insurance) or whether some other party may be responsible (which brings in liability insurance). You’ll need the date of the accident, the name and address of the insurer, and the claim number. That insurer pays first only for care related to that specific injury, not for your other medical needs.⁴

Part 3: How You Qualify for Medicare

Part 3 asks whether you have Medicare because of age (65 or older), disability, or ESRD. Your answer routes you to the right one of the next three parts, because the employer-size rules are different for each basis.

Parts 4, 5, and 6: Group Health Plan Coverage

All three parts ask about group health plan (GHP) coverage through current employment, but they apply to different beneficiaries. Part 4 is for age-based Medicare and asks whether you or your spouse currently work and have employer GHP coverage. Part 5 is for disability-based Medicare and asks whether you or any family member currently works with employer GHP coverage. Part 6 is for ESRD and asks about GHP coverage during the coordination period.⁴

If you have GHP coverage, be ready with the employer’s name and address, the plan’s name, and the policy or group ID number.

The Employer-Size Rule People Get Wrong

Having employer group health coverage does not automatically put Medicare in second place. The employer’s size decides that. If you have Medicare based on age, Medicare is secondary only when the employer has 20 or more employees. If you have Medicare because of a disability, the threshold is 100 or more employees.⁶

Below those thresholds, Medicare pays first even though you have employer coverage. People with coverage from a small employer often assume the employer plan should go first, and answering the questionnaire on that assumption creates the exact mismatch that stalls claims. Know the approximate headcount before you sit down with the form.

Coverage Types That Change Your Answers

Several kinds of coverage have their own coordination rules. If any of these apply to you, your answers will differ from the standard scenarios.

Retiree Health Coverage

If your coverage comes from a former employer’s retiree plan, Medicare pays first and the retiree plan pays second.⁷ The GHP rules that make Medicare secondary apply to current employment, not retiree coverage. That’s why the questionnaire specifically asks whether you or your spouse currently work.

COBRA

For most beneficiaries who have Medicare and COBRA, Medicare pays first and COBRA pays second. The exception is ESRD: if you got Medicare because of end-stage renal disease and your group health plan voluntarily continues coverage, that plan stays primary during the ESRD coordination period.⁸ Outside ESRD, don’t assume COBRA puts Medicare in second place.

ESRD

If you became eligible for Medicare because of permanent kidney failure and you also have employer group health plan coverage, the GHP pays first during a 30-month coordination period.⁹ After that, Medicare becomes primary. Part 6 asks about this directly.

TRICARE

If you’re an inactive-duty military beneficiary getting care from civilian providers, Medicare pays first and TRICARE pays second. On active duty or being treated at a military facility, TRICARE pays first.¹⁰

CHAMPVA

With CHAMPVA benefits through the VA, Medicare pays first and CHAMPVA acts as secondary coverage, which may cover costs Medicare leaves behind, including some or all of your Part B deductible. You have to be enrolled in both Medicare Part A and Part B to keep CHAMPVA.¹¹

Federal Black Lung Benefits

The Federal Black Lung Program pays first for care related to black lung disease. Medicare pays first for everything else. Providers should send black-lung-related bills to that program, not to Medicare.¹²

Fixing a Wrong Answer or an Outdated Record

If Medicare’s records show the wrong insurer as primary, or your situation has changed because you retired, lost employer coverage, or settled an injury claim, the record has to be updated. Contact the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 (TTY: 1-855-797-2627), Monday through Friday, 8:00 a.m. to 8:00 p.m. Eastern Time.¹³ BCRC can investigate conflicting information and update Medicare’s Common Working File so the payer order matches reality.

If your provider’s information about your primary insurer differs from what Medicare’s system shows, call BCRC directly and ask for an investigation. The longer a wrong record stays active, the more claims stack up in the wrong payment order.

What Happens If You Get It Wrong

When Medicare pays a claim that a primary insurer should have paid, either because the other plan is slow or because the questionnaire answers were wrong, the payment is called a “conditional payment.” Medicare has a legal right to recover that money once the primary payer pays.¹⁴

Recovery reaches broadly. CMS can pursue any entity that received a primary payment: the beneficiary, the provider, an attorney, or the insurer. If you get a settlement, judgment, or award from a primary payer and Medicare had already paid some of those same expenses, you have to reimburse Medicare within 60 days.¹⁵

There’s a specific risk if you never file a proper claim with the primary insurer. If Medicare makes a conditional payment because the claim didn’t go to the right payer, and Medicare can’t recover from that payer, CMS can recover from you.¹⁵ Accurate answers on the questionnaire are the simplest way to keep that from happening.

1
Centers for Medicare & Medicaid Services (CMS). Medicare Secondary Payer Manual – Chapter 3 – MSP Provider, Physician, and Other Supplier Billing Requirements
2
Centers for Medicare & Medicaid Services (CMS). Part A Other Insurer Intake Tool
3
CMS: Medicare Secondary Payer (MSP) Manual. Medicare Secondary Payer Manual Chapter 6 – Common Working File Process
4
Centers for Medicare & Medicaid Services (CMS). 20.2.1 – Admission Questions to Ask Medicare Beneficiaries
5
Veterans Affairs. VA Health Care and Other Insurance
6
Centers for Medicare & Medicaid Services. MSP Employer Size for GHP Arrangements Part 1
7
CMS. Medicare Secondary Payer
8
eCFR. Medicare Benefits Secondary to Group Health Plan Benefits
9
Medicare. End-Stage Renal Disease (ESRD)
10
CMS. MLN006903 – Medicare Secondary Payer
11
Veterans Affairs. Getting Care Through CHAMPVA
12
Medicare. Who Pays First?
13
Centers for Medicare & Medicaid Services. Contacts
14
Centers for Medicare & Medicaid Services. Conditional Payment Information
15
eCFR. 42 CFR 411.24 – Recovery of Conditional Payments