Medicaid as the Payer of Last Resort: A Comprehensive Analysis of Its Role as a Secondary Insurance

This report provides a definitive answer to the question of whether Medicaid can serve as a secondary insurance.

The answer is an unequivocal yes; in fact, federal law mandates this role.

This principle, known as “Payer of Last Resort,” is the cornerstone of Medicaid financing and program integrity.

It ensures that all other liable payers—from private employer-sponsored plans to Medicare—meet their obligations before taxpayer-funded Medicaid dollars are expended.

This report will dissect the legal foundations, operational mechanics, and practical implications of this critical function.

We will explore the intricate processes of Third Party Liability (TPL) and Coordination of Benefits (COB), examine the specific scenarios of dual coverage with private insurance and Medicare, analyze the significant variations in state-level implementation, and address the common challenges faced by beneficiaries and providers in navigating this complex system.

I. The Legal and Regulatory Framework: Third Party Liability and Payer of Last Resort

The entire structure that allows Medicaid to function as a secondary insurance is built upon a solid legal and regulatory foundation established at the federal level and implemented by the states.

This framework is designed to preserve the fiscal integrity of the Medicaid program, which is jointly funded by state and federal governments, by ensuring it is the payer of last resort for medical services.¹

The core concepts underpinning this function are the “Payer of Last Resort” doctrine and the principle of Third Party Liability (TPL).

A. Statutory Mandates: The “Payer of Last Resort” Doctrine

The fundamental principle that Medicaid pays only after other resources have been exhausted is enshrined in federal law.

Section 1902(a)(25) of the Social Security Act explicitly requires state Medicaid agencies to take “all reasonable measures to ascertain the legal liability of third parties” to pay for care and services provided to a Medicaid recipient.³

This provision legally establishes Medicaid as the “payer of last resort”.¹

This legal requirement is operationally referred to as Third Party Liability (TPL).

The term signifies that the financial responsibility for a beneficiary’s medical costs lies with a “third party”—an entity other than the Medicaid beneficiary (the first party) or the Medicaid program (the second party).¹

The objective of TPL is to ensure that Medicaid funds are preserved for their intended purpose and to limit the shifting of costs from private insurers and other federal programs onto the state and federal taxpayers who fund Medicaid.¹

To enforce this mandate, states are not only permitted but required to enact their own laws that compel health insurers and other liable entities to cooperate with Medicaid TPL efforts.

These state laws mandate that insurers provide essential data, such as enrollee names, periods of coverage, and policy numbers, to state Medicaid agencies to facilitate the identification of other coverage.³

State-specific examples of this framework in action can be seen in regulations across the country, from Florida’s “Medicaid Third-Party Liability Act” ¹⁰ to Ohio’s detailed administrative code governing coordination of benefits.¹¹

B. Defining a “Third Party”: A Broad and Inclusive Scope

The federal definition of a “third party” is intentionally broad and inclusive to capture the widest possible range of potential payers.

A third party is defined as any individual, entity, or program that is, or may be, legally liable to pay for any medical assistance provided to a Medicaid beneficiary.¹²

This expansive definition is critical to the effectiveness of TPL efforts and includes a diverse array of sources.

The exhaustive list of entities considered third-party payers (TPPs) includes, but is not limited to, the following ⁸:

• Private Health Insurance: This is the most common form of TPL and includes group health plans (GHPs) offered by employers, self-insured plans, and managed care organizations (MCOs).⁹
• Medicare: When a beneficiary is dually eligible for both Medicare and Medicaid, Medicare is the primary payer for all Medicare-covered services.⁷
• Other Public Health Programs: This category includes coverage from military health programs like TRICARE and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).¹
• Workers’ Compensation: If a Medicaid beneficiary is injured on the job, the workers’ compensation insurance plan is liable for the medical costs related to that injury.³
• Liability Insurance: This encompasses payments from casualty insurance policies, such as automobile insurance in the case of a motor vehicle accident or a homeowner’s policy in the event of an injury on the property. Medicaid is entitled to recover its costs from any settlement, judgment, or award from a liability insurer.⁸
• Court-Ordered Medical Support: In cases of divorce or separation, a non-custodial parent may be under a court order to provide health insurance coverage for their children. This coverage is considered a liable third party.³
• Estate Recovery: After the death of certain Medicaid beneficiaries (typically those over age 55 who received long-term care services), states are required to pursue recovery of Medicaid payments from the deceased individual’s estate.¹⁰

The federal mandate for TPL, while fiscally prudent, creates a fundamental tension between the goals of cost containment and ensuring beneficiary access to care.

The administrative complexities imposed on providers to identify, bill, and coordinate with these myriad third parties can be substantial.

This burden can disincentivize providers from treating Medicaid patients who have other insurance, potentially creating access barriers.¹⁸

The very mechanism designed for fiscal prudence can therefore generate a negative externality—reduced access—that federal and state policy must then actively counteract through specific, complex exceptions.

Furthermore, the “Payer of Last Resort” principle transforms Medicaid from a simple health benefit program into a quasi-regulatory entity with broad data collection and recovery powers.

To be the payer of last resort, a state Medicaid agency cannot simply wait for claims to arrive; it must proactively identify other liable payers.³

This requires states to have laws compelling private insurers to share enrollee data, to conduct sophisticated data matches with other public and private entities, and to pursue recovery through legal means like placing liens on tort settlements and estates.³

States often contract with specialized vendors to perform these functions, creating a robust TPL recovery sub-industry.³

This means Medicaid agencies and their contractors operate with significant authority to compel information and recover funds from a vast array of entities, a function far beyond simple claims payment and more akin to that of a tax or revenue agency.

C. Exceptions to the Rule: “Pay and Chase” and Statutory Carve-Outs

While the general rule for TPL is “cost avoidance”—where the state Medicaid agency or its MCO rejects a claim and instructs the provider to bill the primary payer first—federal law recognizes that a rigid application of this rule could create significant barriers to care.⁸

To mitigate this risk, the law establishes important exceptions.

The primary exception is the “pay and chase” model.

Under specific circumstances, a state Medicaid agency is permitted or even required to pay a provider’s claim first (“pay”) and then seek reimbursement (“chase”) from the liable third party.⁵

This approach shifts the administrative burden of pursuing the TPL from the healthcare provider to the state, which is better equipped to handle it.

This is considered essential for services where any delay or administrative hurdle in payment might discourage providers from participating in the Medicaid program altogether.

Federal law has historically required the “pay and chase” approach for certain sensitive services, including:

• Preventive pediatric services, including all services covered under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which is a comprehensive and preventive health benefit for children under 21.⁵
• Services delivered to children who are covered by medical support orders from a court.⁵
• Prenatal and delivery-related services for pregnant women, although the Bipartisan Budget Act of 2018 provided states with more flexibility in this area, allowing them to use cost avoidance for these claims as well.⁵

In addition to the “pay and chase” exceptions, there is a small category of public programs that are statutorily designated as payers of last resort after Medicaid.

This creates a reverse payment hierarchy.

These programs include the Ryan White HIV/AIDS Program, Title V Maternal and Child Health block grants, and programs administered by the Indian Health Service.⁶

Some states also define their own specific exceptions.

For example, Ohio’s administrative code specifies that Medicaid pays before state programs for children with medical handicaps and state-sponsored reparations for victims of crime.¹¹

II. The Mechanics of Coordination of Benefits (COB)

The legal mandate of Third Party Liability is put into practice through a set of operational processes known as Coordination of Benefits (COB).

COB refers to the activities involved in determining payment responsibilities when a Medicaid beneficiary is covered by more than one health plan.³

It is the “how-to” of the TPL system, ensuring the orderly transfer of information and the correct application of payments to avoid both duplicate payments and gaps in coverage.¹⁴

A. Identifying Third Party Liability: Data as the Linchpin

The entire COB process is critically dependent on the accurate and timely identification of a Medicaid beneficiary’s other health insurance.

If the state is unaware of a liable third party, it will incorrectly pay claims as the primary payer.

Conversely, if the state’s records show outdated TPL information for a beneficiary who has lost their other coverage, it will incorrectly deny claims, creating significant access barriers.²⁵

This data dependency explains why federal and state governments have invested heavily in complex data exchange infrastructure and why states are required to use multiple methods to identify TPL.³

States employ several key methods to gather this crucial information:

• Beneficiary Reporting: The process begins at the point of application. As a condition of eligibility, individuals applying for Medicaid must disclose any other health insurance coverage they or their family members have. This information is required to be reviewed and updated periodically, typically at the time of the beneficiary’s annual eligibility redetermination.³
• Data Matching and Exchanges: This is the most systematic and robust method for identifying TPL. State Medicaid agencies are required to have laws in place that compel health insurers to provide their plan eligibility and coverage information.³ States then conduct data matches against these and other databases to find overlaps with their Medicaid rolls.³ These data matching efforts include:

• Federal Data Exchange Hubs: The Centers for Medicare & Medicaid Services (CMS) plays a central role in facilitating data sharing. The COB Agreement (COBA) program, for instance, establishes a national standard contract and data repository that allows state Medicaid agencies, Medicare, Medigap plans, and employer supplemental plans to exchange eligibility data and Medicare paid claims data automatically. This is the primary mechanism for processing “crossover claims” for dual eligibles.¹⁴ CMS also maintains Voluntary Data Sharing Agreements (VDSAs) with numerous large employers to electronically exchange group health plan enrollment information.¹⁴
• Mandatory Insurer Reporting: Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) created mandatory reporting requirements for group health plans and liability, no-fault, and workers’ compensation insurers.¹⁴
• Other Public and Private Databases: States routinely match data with other public agencies, such as the Department of Defense to identify TRICARE coverage, as well as with state workers’ compensation databases and state motor vehicle accident files to identify potential liability claims.¹

Once TPL is identified and verified, the information is recorded in the beneficiary’s Medicaid eligibility file.

This often results in a special code or indicator being printed on the beneficiary’s Medicaid ID card, which serves as a flag to healthcare providers that other insurance must be billed first.¹¹

B. The Claims Processing Waterfall: A Step-by-Step Guide

When a Medicaid beneficiary with known TPL receives a medical service, the billing and payment process follows a clear, sequential hierarchy often described as a “claims processing waterfall”.²⁷

This structured process ensures that each payer meets its obligation in the correct order.

• Step 1: Provider Bills the Primary Payer. The healthcare provider is responsible for submitting the initial claim for services directly to the identified primary payer. This could be a commercial insurance plan, an employer-sponsored plan, or Medicare.⁷ A critical prerequisite for the beneficiary is to seek care from a provider who is in-network and accepts their primary insurance plan. Failure to do so may result in the primary plan denying the claim or paying at a lower out-of-network rate, and could leave the beneficiary responsible for the bill.⁸
• Step 2: Primary Payer Adjudicates the Claim. The primary insurer processes the claim according to the terms of its policy. It determines the covered amount and the beneficiary’s cost-sharing responsibility (e.g., deductible, coinsurance, or copayment). The insurer then issues an Explanation of Benefits (EOB) or a Remittance Advice (RA) to the provider and/or the beneficiary. This document is essential for the next step, as it details exactly what the primary plan paid, what it denied, and the reasons for its decisions.⁸
• Step 3: Provider Bills Medicaid as the Secondary Payer. After receiving the EOB/RA from the primary payer, the provider submits a secondary claim to the state Medicaid agency or the beneficiary’s Medicaid MCO. This secondary claim is not a simple resubmission of the original bill. It must be accompanied by the information from the primary payer’s EOB/RA. This includes the amount paid by the primary plan and, crucially, the specific Claim Adjustment Reason Codes (CARCs) that explain why the full charge was not paid.²⁵ These codes are vital for the secondary payer to understand the remaining liability.
• Step 4: Medicaid Adjudicates the Secondary Claim. The Medicaid agency or MCO then processes the secondary claim. Its payment is based on the information provided from the primary payer and is limited by Medicaid’s own rules and payment rates. Medicaid will typically cover the beneficiary’s remaining cost-sharing obligations, but only up to the state’s established Medicaid-allowable rate for that specific service.¹¹

This waterfall process creates a complex web of financial and administrative obligations that can easily lead to disputes and errors.

The provider is tasked with navigating the distinct rules of at least two different payers, each with its own billing requirements, timely filing deadlines, and fee schedules.²¹

A simple procedural error, such as failing to include the correct CARC codes from the primary EOB on the secondary claim, can cause the Medicaid claim to be denied.³⁰

The beneficiary is often caught in the middle, responsible for providing correct and up-to-date insurance information and frequently facing confusion when a provider’s office struggles with the complex billing process.¹⁸

This complexity is a major source of friction in the system and can result in providers writing off balances they are legitimately owed, ultimately impacting their financial viability and willingness to serve this population.

C. Cost Avoidance vs. Pay and Chase: Strategic Implementation

In managing TPL, state Medicaid programs primarily use two distinct strategies: cost avoidance and pay and chase.

The choice of strategy is dictated by federal rules and state policy, and it determines where the initial administrative burden for pursuing TPL lies.

• Cost Avoidance: This is the default and most common TPL strategy. When a provider submits a claim for a beneficiary who is known to have other primary insurance in the state’s eligibility system, the Medicaid claims processing system will automatically reject, or “cost avoid,” the claim.⁶ The rejected claim is returned to the provider with a notification identifying the liable third party and instructing the provider to bill that primary payer first. Only after the primary payer has adjudicated the claim can the provider resubmit a secondary claim to Medicaid. This approach squarely places the administrative burden of coordinating benefits on the healthcare provider.
• Pay and Chase: As previously discussed, this is the exception to the rule, designed to protect access to care for certain vulnerable populations or sensitive services.⁵ In a “pay and chase” scenario, the state Medicaid agency pays the provider’s claim as if it were the primary payer and then assumes the responsibility of pursuing, or “chasing,” reimbursement from the liable third party after the fact.⁵ This shifts the administrative burden from the provider to the state. Louisiana provides a clear example of services subject to this model, such as preventive pediatric care and most services under the EPSDT benefit.²² This strategy is critical for ensuring that providers of essential services are not deterred from participating in Medicaid by the complexities of TPL.

III. Medicaid as Secondary to Private and Employer-Sponsored Insurance

One of the most frequent scenarios in which Medicaid acts as a secondary payer involves beneficiaries who have concurrent coverage from a private or employer-sponsored health insurance plan.

This often occurs in low-income working families where an individual may be eligible for Medicaid based on income but also has access to a commercial health plan through their own or a family member’s job.

In this context, Medicaid provides a crucial financial safety Net.

A. Covering Cost-Sharing Obligations: The “Wrap-Around” Benefit

When Medicaid is secondary to a private commercial plan, one of its most valuable functions is to provide “wrap-around” coverage.²³

Commercial health plans, even those with comprehensive benefits, typically require significant out-of-pocket payments from members in the form of deductibles, copayments, and coinsurance.

For a low-income family, these costs can be prohibitive and act as a major barrier to accessing needed care.

Medicaid’s wrap-around benefit helps to bridge this gap by covering these cost-sharing obligations.⁹

The process works as follows:

• After the primary commercial plan pays its portion of a medical bill, the remaining balance, which represents the patient’s liability, is submitted to Medicaid.
• Medicaid may then pay some or all of this remaining amount. For example, if a primary plan covers a doctor’s visit but leaves the patient with a $30 copayment, Medicaid may pay that $30 for the beneficiary.³⁴
• Similarly, if a primary plan covers 80% of a hospital stay, leaving the patient responsible for 20% coinsurance, Medicaid may pay that 20% share.³⁴

This function is critical for making healthcare truly accessible and affordable for low-income working individuals and families who would otherwise be “underinsured”—having a health insurance policy but still facing unaffordable out-of-pocket costs.

B. The Medicaid Rate as a Payment Ceiling: A Critical Limitation

A crucial and often misunderstood aspect of Medicaid’s role as a secondary payer is the strict limit on its payment liability.

The total reimbursement a healthcare provider can receive from both the primary commercial insurer and the secondary Medicaid payment combined cannot exceed the amount that Medicaid would have paid for that service if it were the sole payer.

This is known as the Medicaid-allowable rate or fee schedule amount.¹¹

This payment ceiling leads to two distinct scenarios:

• Scenario 1: Primary Payment Exceeds or Equals the Medicaid Rate. Commercial insurance plans often reimburse providers at rates higher than state Medicaid programs. If the payment from the primary commercial plan is equal to or greater than the state’s Medicaid-allowable rate for a given service, Medicaid will make no additional payment ($0). In this situation, the provider is legally required to accept the primary insurer’s payment as payment in full. They are prohibited from “balance billing” the beneficiary for any remaining copayment or coinsurance amount that was part of the primary plan’s EOB.³¹
• Scenario 2: Primary Payment is Less than the Medicaid Rate. If the primary commercial insurer’s payment is less than the Medicaid-allowable rate, Medicaid will pay the lesser of two amounts: either the beneficiary’s cost-sharing liability (the deductible, copay, and coinsurance) or the difference between the primary payment and the Medicaid rate.¹¹

This payment ceiling rule is a fundamental cost-containment mechanism.

It protects the Medicaid program from being responsible for the often high cost-sharing structures of private plans, especially for services that have already been reimbursed at a level that meets or exceeds what Medicaid itself considers a reasonable payment.

However, this rule creates significant financial disincentives for providers, particularly specialists, to treat patients with private primary insurance and Medicaid secondary.

A provider might see a patient with only a commercial plan and expect to collect a payment from the insurer plus a copay from the patient.

If that same patient also has Medicaid secondary and the commercial plan’s payment already exceeds the Medicaid rate, the provider is legally barred from collecting that copay.

This results in the provider receiving a lower total payment for the dually-covered patient than for a patient with only commercial insurance.

This effective financial “haircut” can lead providers to limit the number of dually-covered patients they accept, creating a tangible access-to-care problem.¹⁸

C. State Premium Assistance Programs: HIPP and CHIPRA

Recognizing that many Medicaid-eligible individuals have access to private insurance, states have developed programs to leverage this coverage in a cost-effective manner.

Instead of covering a person’s medical costs directly on a fee-for-service basis, it can sometimes be more economical for the state to help that person pay for their private insurance.

• Health Insurance Premium Payment (HIPP) Program: Under the HIPP program, a state Medicaid agency can pay the monthly premiums for an eligible beneficiary’s employer-sponsored health insurance plan. This is only done when a state analysis determines that it is cost-effective to do so—meaning the cost of the premiums is less than the anticipated cost of the beneficiary’s medical claims if Medicaid were to cover them directly.⁷ When a beneficiary is enrolled in HIPP, their private plan remains the primary payer, and Medicaid provides secondary, wrap-around coverage for cost-sharing and services not covered by the private plan. This approach represents a strategic policy choice by states to leverage the private insurance market for Medicaid populations, shifting the bulk of the cost to the private market while still providing a comprehensive safety net.
• Children’s Health Insurance Program Reauthorization Act (CHIPRA) Premium Assistance: Similar to HIPP, CHIPRA, enacted in 2009, provides states with options to offer premium assistance for employer-sponsored insurance for children in low-income families who might otherwise be eligible for Medicaid or the Children’s Health Insurance Program (CHIP).¹⁷

The effectiveness of these premium assistance programs hinges on careful and continuous cost-benefit analysis.

The state must have a robust system to identify eligible individuals and accurately calculate whether paying premiums will indeed result in savings.

The administrative overhead of managing the program must be outweighed by the fiscal benefits generated.

These programs illustrate the hybrid nature of the U.S. healthcare system, representing a market-based approach embedded within a public insurance framework.

IV. The Special Case of Dual Eligibility: Coordinating Medicare and Medicaid

A unique and highly complex area of secondary coverage involves the more than 12 million low-income seniors and people with disabilities who are simultaneously eligible for both Medicare and Medicaid.³⁷

These “dual eligibles” represent one of the sickest and most costly populations in the U.S. healthcare system, and coordinating their benefits between the nation’s two largest public insurance programs is a significant policy and administrative challenge.²

A. The Dual Eligible Population: Full vs. Partial Benefits

The term “dual eligible” is not monolithic; it encompasses several distinct categories of beneficiaries based on their income and resource levels, which determine the extent of their Medicaid benefits.⁹

• Full-Benefit Dual Eligibles: These individuals meet the stringent income and asset criteria for full Medicaid benefits in their state. For this group, Medicare is the primary insurer, and Medicaid provides a comprehensive secondary, wrap-around benefit.³⁹ Medicaid covers most Medicare cost-sharing and also pays for critical services that Medicare does not cover, most notably long-term services and supports (LTSS), such as nursing home care and extensive home and community-based services, as well as benefits like dental, vision, and non-emergency medical transportation.¹⁵
• Partial-Benefit Dual Eligibles: This group consists of Medicare beneficiaries with incomes slightly too high to qualify for full Medicaid but low enough to receive assistance with their Medicare costs through a set of programs known as the Medicare Savings Programs (MSPs).³⁹ For these individuals, Medicaid’s secondary role is limited to paying for some or all of their Medicare premiums and/or cost-sharing. The primary MSPs, in order of generosity, are:

• Qualified Medicare Beneficiary (QMB): This is the most comprehensive MSP. For QMBs, Medicaid pays the Medicare Part A (if applicable) and Part B premiums, as well as all Medicare deductibles, coinsurance, and copayments. Federal law prohibits providers from billing QMB beneficiaries for any Medicare cost-sharing.²³
• Specified Low-Income Medicare Beneficiary (SLMB): For SLMBs, Medicaid pays only the Medicare Part B premium.²⁶
• Qualifying Individual (QI): For QIs, Medicaid also pays only the Medicare Part B premium.²⁶

The existence of these different categories means that the label “dual eligible” masks significant heterogeneity in the actual benefits received and the level of financial protection afforded to the beneficiary.

A full-benefit dual eligible enjoys comprehensive coverage with minimal out-of-pocket costs, while a partial-benefit dual eligible in the SLMB program is still responsible for all Medicare deductibles and coinsurance, representing a far less robust safety Net.

B. Medicare as Primary Payer: The Coordination Hierarchy

For all dual eligibles and for any service covered by both programs, the payment hierarchy is unambiguous and federally mandated: Medicare is always the primary payer, and Medicaid is the secondary payer of last resort.⁷

• Medicare Part A (Hospital Insurance) and Part B (Medical Insurance): When a dual eligible receives a service covered by Medicare Part A or B, the provider must bill Medicare first. After Medicare processes the claim and pays its share, the claim information is automatically transmitted—or “crossed over”—to the state Medicaid agency. This is facilitated by the national COBA system.¹⁴ Medicaid then pays the remaining Medicare deductible and coinsurance, subject to state rules and limits.
• Medicare Part D (Prescription Drug Coverage): The Medicare Modernization Act of 2003 shifted prescription drug coverage for dual eligibles from Medicaid to Medicare Part D. Dual eligibles must enroll in a Medicare Part D plan to receive coverage for most of their medications. They automatically qualify for the Part D Low-Income Subsidy (LIS), also known as “Extra Help,” which dramatically reduces their premiums, deductibles, and copayments.⁹ While Part D is the primary drug payer, Medicaid may still cover a few specific classes of drugs that are statutorily excluded from Part D coverage, such as benzodiazepines and barbiturates.¹⁵

C. Integrated Care Models: Streamlining a Fractured System

Navigating two separate, uncoordinated fee-for-service systems—one for Medicare and another for Medicaid—is exceptionally difficult for beneficiaries and inefficient for the government.

This fragmentation often leads to poor care coordination, conflicting incentives, and cost-shifting between the federal government (which largely funds Medicare) and the states (which share the cost of Medicaid).⁴³

In response to this challenge, CMS and states have actively promoted integrated care models designed to align financing and coordinate benefits for dual eligibles, almost always through managed care platforms.³⁸

The drive to solve the coordination failure inherent in the dual-eligible structure has made this population a primary driver of managed care innovation in public insurance programs.

The immense cost and complexity of this group created enormous pressure on policymakers to find better solutions, resulting in the development and evolution of several key models:

• Dual Eligible Special Needs Plans (D-SNPs): These are a specific type of Medicare Advantage (Part C) plan that is permitted to exclusively enroll dual-eligible individuals. A key requirement is that D-SNPs must have a contract with the state Medicaid agency to coordinate the delivery of benefits.³³ There are varying levels of integration among D-SNPs, representing a policy evolution toward deeper coordination:

• Coordination-Only D-SNPs: The most basic level, requiring only that the plan coordinate with the state.
• Highly Integrated D-SNPs (HDE-SNPs): The D-SNP and a state Medicaid managed care plan are operated by the same parent organization, facilitating better alignment.
• Fully Integrated D-SNPs (FIDE-SNPs): This is the highest level of integration, where a single health plan provides all Medicare and Medicaid benefits to members who are enrolled in both its Medicare and Medicaid products. This model aims to provide a seamless experience with one insurance card and one care management system.³⁹

• Program of All-Inclusive Care for the Elderly (PACE): PACE is a highly integrated, capitated model of care for frail elders who are certified as needing a nursing home level of care but are able to live safely in the community. PACE programs become the sole provider and coordinator of all Medicare and Medicaid services, including medical care, long-term services, social activities, and transportation, all managed by an interdisciplinary team at an adult day health center.¹⁵
• Medicare-Medicaid Plans (MMPs): Created under the federal Financial Alignment Initiative (FAI), MMPs were demonstration projects in several states designed to test models of full financial and clinical integration. These plans operated under a three-way contract between CMS, the state, and a health plan to provide a comprehensive, coordinated benefit package for dual eligibles.³⁹

These models represent a clear policy trend away from fragmented fee-for-service care and toward integrated, managed care solutions to control costs and improve the quality of care for this uniquely vulnerable and complex population.

V. State-Level Implementation and Variation: A Comparative Analysis

While federal law establishes the overarching “Payer of Last Resort” mandate, Medicaid is administered by each state and territory.

This structure grants states considerable flexibility in how they design and implement their programs, leading to a patchwork of different rules, processes, and operating environments across the country.²

This variation is particularly evident in how states manage Third Party Liability and the Coordination of Benefits.

A national health system, a provider operating in multiple states, or a beneficiary moving across state lines cannot assume that TPL rules are portable.

Compliance and navigation strategies must be tailored to the specific state, adding a significant layer of complexity to the healthcare system.

A. The Role of Managed Care Organizations (MCOs) in TPL

The majority of Medicaid beneficiaries nationwide are now enrolled in private Managed Care Organizations (MCOs) that contract with the state to provide health services.²³

In this capitated model, states delegate many administrative functions, including TPL and COB, to their MCOs.

The specific contract between the state and the MCO dictates the terms and conditions under which the MCO must identify other insurance, cost-avoid claims, and coordinate benefits.³

This means that for a beneficiary enrolled in a Medicaid managed care plan, it is the MCO—not the state’s fee-for-service agency—that is responsible for acting as the secondary payer.⁸

Providers must therefore navigate not only the state’s rules but also the specific procedures of each individual MCO with which they contract.

B. State-Specific Rules and Programs: A Comparative Look

The differences in how states approach TPL can be substantial.

A comparative analysis of a few key states illustrates the degree of variation.

• Texas: The Texas Medicaid program adheres strictly to the payer of last resort principle.⁴⁴ However, it has a significant and unique exception for its Texas Health Steps (THSteps) program, which is the state’s version of the federal EPSDT benefit for children. For THSteps services, providers are
  not required to bill a known primary insurance first. They have the option to bill Medicaid directly, but if they do so, they must accept the Medicaid payment as payment in full and forfeit any right to pursue payment from the other insurer.⁴⁴ This is a major operational difference for pediatric providers in Texas compared to other states. For all other services, secondary claims must be submitted to the Texas Medicaid & Healthcare Partnership (TMHP) or the relevant MCO within 95 days of the primary payer’s EOB.³¹
• New York: New York regulations also firmly establish Medicaid as the payer of last resort.⁴⁶ The state places a strong emphasis on TPL for pharmacy benefits through its NYRx program. Pharmacists are required to bill any known TPL first and must use the state’s online portal, ePACES, to verify a beneficiary’s TPL status if it is unknown.⁴⁸ This creates a technology-dependent compliance pathway. For dual eligibles, New York policy explicitly reminds its Managed Long Term Care (MLTC) plans of their responsibility to coordinate Medicare benefits, particularly for services like skilled home health care that may be covered by Medicare as the primary payer.⁴⁷
• Florida: Florida has one of the most detailed regulatory frameworks for TPL, codified in the Florida Administrative Code.⁴² The rules provide specific formulas for calculating secondary reimbursement, including for providers who have discounted contract rates with primary payers. The Florida rules also explicitly detail how the state pays Medicare premiums and cost-sharing for each category of dual eligible (QMB, SLMB, etc.). Notably, for Medicare Part B services that are not covered by Florida Medicaid, the state will still pay the Medicare cost-sharing for QMBs, but it caps the payment at 50% of the Medicare-allowed amount.⁴²
• Ohio: Ohio’s administrative code is highly prescriptive regarding what constitutes “reasonable measures” for a provider to attempt to collect from a TPP before billing Medicaid. For instance, a provider is considered to have met this standard if they have submitted a claim to the TPP at least three times within a ninety-day period without receiving a response.¹¹ Uniquely, Ohio’s code also specifies a list of public programs that are considered payers
  after Medicaid, including the state’s program for children with medical handicaps and the crime victims’ compensation fund, a level of state-specific determination not commonly seen elsewhere.¹¹

C. Comparative Analysis of State TPL/COB Policies

The following table synthesizes these state-level variations into a clear comparative framework, highlighting key differences in operational requirements.

Feature	Texas	New York	Florida	Ohio
Key TPL Statute/Rule	Texas Medicaid Provider Procedures Manual (TMPPM)	NY Social Services Law; NYRx Pharmacy Manual	Fla. Admin. Code Ann. R. 59G-1.052; F.S. 409.910	Ohio Admin. Code 5160-1-08
“Pay and Chase” Policy	Mandated for THSteps (EPSDT) services; provider has option to bill Medicaid first.44	Generally cost-avoidance, but exceptions exist. Strong emphasis on billing TPL first for pharmacy.46	Primarily cost-avoidance; providers must exhaust TPL sources before billing Medicaid.42	“Pay and Chase” for preventive pediatric services; otherwise, cost-avoidance.11
Provider Billing Deadline (Secondary Claim)	Within 95 days of primary payer’s EOB/RA.31	Timely filing rules apply; must exhaust TPL first.46	Within 12 months of DOS or 6 months of Medicare disposition.42	Must take “reasonable measures” (e.g., 3 attempts in 90 days) before billing Medicaid.11
Unique Programs/Exceptions	THSteps exception; STAR+PLUS for duals.44	NYRx pharmacy program with specific COB rules via ePACES.48	Detailed rules for discounted TPL contracts; specific reimbursement for QMBs.42	Defines specific non-TPR sources that pay after Medicaid (e.g., crime victim fund).11

VI. Navigating the System: Challenges, Disputes, and Advocacy

While the policies and processes governing Medicaid as a secondary payer are well-defined in law and regulation, the real-world application of these rules presents significant challenges for both beneficiaries and the healthcare providers who serve them.

Navigating this complex system requires diligence, expertise, and often, advocacy to resolve the disputes that inevitably arise.

A. Common Obstacles for Beneficiaries and Providers

The intersection of two or more insurance plans creates multiple potential points of failure that can disrupt access to care and create administrative burdens.

• Provider Network Misalignment: A primary and persistent challenge is finding healthcare providers who are in-network for both a beneficiary’s primary commercial insurance plan and their secondary Medicaid plan (or their specific Medicaid MCO).¹⁸ A beneficiary may have to choose between seeing their established primary care doctor who does not accept Medicaid, thereby forfeiting the wrap-around benefit for cost-sharing, or finding a new provider who accepts both plans. This can be particularly difficult when seeking specialist care.
• Administrative Burden and Provider Refusal: The sheer complexity of billing two different payers, each with its own rules, fee schedules, and timely filing limits, is a significant deterrent for many provider offices.¹⁸ This administrative hassle, combined with the “Medicaid rate as ceiling” rule that can lead to lower overall reimbursement, results in some providers refusing to accept patients with Medicaid as a secondary insurance. Others may misunderstand the rules and incorrectly balance bill the patient for costs that should have been written off, leading to confusion and financial distress.¹⁹
• Incorrect TPL Information: As previously noted, the COB system is highly dependent on accurate data. A frequent source of frustration for beneficiaries and providers is when the state’s eligibility system contains incorrect or outdated TPL information. If the system incorrectly shows that a beneficiary has other insurance when they do not, their claims will be improperly denied by Medicaid. The burden then falls on the beneficiary to contact the state or local Medicaid agency to correct the record, a process that can be time-consuming and delay access to care and payment.²⁵
• Patient Confusion: Beneficiaries are often caught in the middle of these complex interactions. They may receive confusing denial notices or bills from providers and may not understand why a claim was denied or what steps they need to take to resolve the issue.²⁵

B. Understanding Claim Denials in a Secondary Payer Context

A claim denial in a secondary payer context can be particularly confusing because it can originate from either the primary or the secondary payer, and the reasons are often procedural rather than clinical.⁵⁰

Common reasons for the denial of a secondary Medicaid claim include:

• Procedural and Billing Errors: The provider may have billed Medicaid before billing the primary payer, failed to attach the required EOB from the primary payer, or used incorrect coding on the secondary claim.³⁰
• Service Not a Covered Medicaid Benefit: The primary commercial plan may cover a particular service, but if that service is not a covered benefit under the state’s Medicaid plan, Medicaid will not pay the remaining cost-sharing.³⁴
• Primary Payment Exceeded the Medicaid Rate: As detailed previously, if the primary insurer’s payment met or exceeded the Medicaid-allowable rate, the secondary claim will be processed with a $0 payment. While technically not a “denial” of the service, it appears as such to the provider seeking additional reimbursement and confirms that no further payment is due.³¹
• Lack of Prior Authorization: A service may not require prior authorization under the primary plan’s rules, but it may require it under Medicaid’s rules. If the provider failed to obtain prior authorization from Medicaid before rendering the service, the secondary claim can be denied on that basis.⁵⁰

C. The Appeals and Grievance Process: Avenues for Recourse

Beneficiaries have a federally protected right to appeal a health plan’s decision to deny payment for a claim or authorization for a service.⁵¹

However, in a dual-coverage situation, the appeals process itself is bifurcated, mirroring the complexity of the payment system.

A single medical event could potentially trigger two separate and distinct appeal processes.

• Appealing a Primary Plan Denial: If the primary commercial insurer or Medicare denies a claim or service (e.g., for not being “medically necessary”), the beneficiary must use that plan’s internal and external appeals process. The first step is an internal appeal, which is a formal request for the insurance company to conduct a full and fair review of its decision. If that is unsuccessful, the beneficiary has the right to an external review, where an independent third party reviews the case and makes a binding decision.⁵³ Medicaid is not yet involved in this stage of the dispute.
• Appealing a Medicaid Denial or Filing a Grievance: If the primary plan pays its share but the secondary claim is denied by the state Medicaid agency or the MCO, the beneficiary must use the appeal and grievance process established by that Medicaid entity.⁵⁵ A
  grievance can be filed for issues beyond claim denials, such as complaints about quality of care, provider attitude, or problems with access.⁵⁵ Many states and MCOs have
  Ombudsman programs or other member advocates who are tasked with helping beneficiaries understand their rights and navigate these complex processes.⁵⁵ Non-profit patient advocacy organizations also provide crucial support and resources for patients facing claim denials.⁵¹

This dual-track system places an enormous burden on beneficiaries, who may need to navigate two different sets of rules, timelines, and paperwork for the same health issue.

Effective patient advocacy in this context requires not just clinical knowledge, but deep expertise in insurance billing procedures and data management.

Many denials are not based on clinical disagreements but on procedural or data errors.

An effective advocate must be able to diagnose the specific point of failure in the COB waterfall—whether it is an incorrect TPL record at the state, a missing EOB on the provider’s claim, or a misapplication of the payment ceiling rule—and target their intervention accordingly.

This requires a highly specialized skill set that blends clinical understanding with administrative and financial acumen.

Conclusion and Recommendations

Medicaid’s function as a secondary insurance is a cornerstone of its design, mandated by federal law to ensure program integrity and preserve taxpayer resources.

This role is governed by the “Payer of Last Resort” principle and operationalized through the complex machinery of Third Party Liability and Coordination of Benefits.

While this structure is fiscally essential, it creates a labyrinth of rules, processes, and potential pitfalls for the beneficiaries it is meant to serve and the providers who deliver their care.

The system’s effectiveness hinges on the seamless flow of accurate data, the diligence of providers in navigating multi-payer billing, and the ability of states to balance cost-containment with ensuring access to care.

For individuals with dual coverage—whether through private insurance or Medicare—Medicaid provides a vital financial safety net, but one that is often tangled in administrative complexity.

Recommendations for Policymakers

• Streamline and Standardize COB: Federal and state policymakers should continue to invest in and promote national standards for electronic data exchange, expanding on the success of the COBA program. This would reduce the friction, errors, and administrative costs caused by state-by-state variations in data requirements and manual processes.
• Promote Integrated Care: For the dual-eligible population, policymakers should continue to incentivize and expand fully integrated care models like FIDE-SNPs and PACE. These models have the greatest potential to reduce administrative burden for states, providers, and beneficiaries, while improving care coordination and health outcomes.

Recommendations for Healthcare Providers

• Invest in Billing Expertise: Provider organizations must ensure that their front-desk and billing staff are thoroughly trained on the specific TPL/COB rules for each state and Medicaid MCO they work with. This training must include a clear understanding of the “Medicaid rate as ceiling” limitation to prevent improper billing and manage revenue cycle expectations.
• Implement Pre-Service Verification: A robust workflow to verify a patient’s primary and secondary insurance coverage, including their network status with each plan, before a service is rendered is essential. This proactive step can prevent a significant number of downstream denials, patient frustration, and uncollectible debt.

Recommendations for Beneficiaries and Advocates

• Maintain Accurate Records: Beneficiaries must be educated on the importance of proactively reporting any changes in their health insurance coverage—such as gaining or losing a job with health benefits—to their state Medicaid agency immediately. This is the most effective way to prevent data-related claim denials.
• Understand and Exercise Appeal Rights: Beneficiaries and their advocates must be aware of their right to appeal denials from both the primary and the secondary payer. They should always request denial reasons in writing and utilize state-provided ombudsman programs, legal aid services, and non-profit consumer assistance programs for help in navigating these complex processes.

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