Primary, Secondary & Catastrophic Insurance.

When a student-athlete suffers an injury while playing intercollegiate sport in the United States, one of the first concerns is naturally their recovery.

But shortly afterwards comes another important question:

Who pays the medical bills?

The answer isn't always straightforward.

Depending on the college, the athlete's personal health insurance and the circumstances surrounding the injury, there can be several different layers of insurance involved.

Understanding the difference between primary, secondary and catastrophic medical insurance can therefore be extremely important for student-athletes and their families.

Primary Medical Insurance

Primary insurance is generally the first insurance policy that responds to an eligible medical claim.

For many student-athletes, this could be:

• A parent's or guardian's health insurance plan

• The student's own health insurance

• An insurance policy arranged specifically for the student-athlete

When an athlete requires treatment following an injury, the medical provider will normally submit the eligible claim to the primary insurer first.

The primary insurer then processes the claim according to the terms of that particular policy.

That last point is important.

Having health insurance does not necessarily mean that every dollar of treatment will be covered.

A policy may contain:

• Deductibles

• Co-payments

• Co-insurance

• Provider-network restrictions

• Treatment limits

• Pre-authorisation requirements

• Exclusions for certain activities or treatments

For an international student-athlete, it is particularly important to understand whether their medical insurance provides suitable coverage for treatment in the United States and for injuries arising from participation in intercollegiate sport.

What Happens When the College Has Secondary Insurance?

This is where secondary insurance can become important.

Some colleges and universities maintain an athletics accident insurance policy designed to provide secondary or excess coverage for eligible intercollegiate sporting injuries.

Imagine, for example, that a student-athlete suffers a serious knee injury during an authorised college soccer game.

The athlete's primary medical insurance may be billed first.

After that policy has processed the claim, there may still be eligible expenses remaining. Depending upon the terms of the institution's athletics accident policy, the secondary policy may then respond to some or all of those remaining eligible costs.

A simplified example might look like this:

Medical treatment following a sports injury: $30,000

Step 1 – Primary insurance

The athlete's primary medical insurer processes the claim first.

Step 2 – Secondary insurance

Eligible expenses remaining after the primary insurer has processed the claim may then be submitted to the college's secondary athletics accident insurance.

Step 3 – Remaining expenses

Any amount not covered by either policy will depend upon the respective policy terms and the institution's arrangements.

It is important not to assume that every college operates in exactly the same way.

The NCAA specifically notes that coverage gaps can still occur—for example, where treatment is out of network or where deductibles, co-pays or other expenses are not fully covered.

What Does the NCAA Require?

For NCAA student-athletes, there is an important insurance requirement.

Before participating in practice or competition, NCAA member schools must certify that student-athletes have medical insurance covering athletically related injuries up to at least the deductible of the NCAA Catastrophic Injury Insurance Program.

That deductible is currently $90,000.

The required underlying coverage can potentially come from several sources, including:

• A parent or guardian's insurance

• The student-athlete's personal insurance

• An accident medical policy maintained by the institution

• A formal self-insurance arrangement maintained by the institution

In other words, the NCAA requirement does not mean that every college must simply pay every athletics-related medical bill through its own insurance policy. The structure used to satisfy the requirement can differ between institutions.

What Is Catastrophic Medical Insurance?

The third layer is catastrophic insurance.

The NCAA sponsors a Catastrophic Injury Insurance Program for active member institutions.

This is designed as excess coverage, rather than a replacement for the insurance that sits underneath it.

Currently, the program can begin responding once covered medical expenses exceed the $90,000 deductible threshold, after other valid and collectible insurance has been applied.

An important distinction is that an injury does not necessarily have to sound "catastrophic" in everyday language for the program potentially to apply. According to the NCAA, if an otherwise covered injury generates eligible expenses above the deductible threshold, catastrophic benefits may potentially be triggered.

Think of Insurance as Three Layers

A useful way for student-athletes and parents to understand the system is to picture three layers:

PRIMARY INSURANCE

↓

The athlete's main health insurance responds first.

SECONDARY / EXCESS ATHLETICS INSURANCE

↓

Where provided and applicable, the institution's athletics accident coverage may respond to eligible expenses remaining after primary insurance.

CATASTROPHIC INSURANCE

↓

For eligible NCAA athletics injuries where covered expenses exceed the current $90,000 catastrophic-program deductible, the NCAA Catastrophic Injury Insurance Program may then provide excess benefits.

The exact journey of a claim will depend on the insurance arrangements in place at the individual institution and the terms and conditions of each applicable policy.

Why Primary Insurance Still Matters

It can be tempting to think:

"If my college has athletics insurance, why do I need my own medical insurance?"

There are several reasons.

Firstly, institutional athletics coverage may only apply to injuries arising from qualifying intercollegiate athletics activities.

A student-athlete can still become ill, have an accident away from organised sport or require treatment for something completely unrelated to their team.

Secondly, the college's policy may operate as secondary or excess insurance, meaning another valid medical insurance policy is expected to respond first.

Thirdly, insurance networks matter.

The NCAA itself highlights the example of a family health plan that technically satisfies the insurance requirement but may leave problems if medical providers close to the student's college are outside that insurer's network.

For international student-athletes living thousands of miles from home, understanding these details before arriving in the United States can be particularly valuable.

What About Treatment After College?

There is another important development student-athletes and families should know about.

The NCAA's Post-Eligibility Insurance Program provides eligible student-athletes with excess accident medical coverage for qualifying intercollegiate athletics injuries for up to two years (104 weeks) after they separate from school or voluntarily withdraw from athletics.

The program applies to qualifying injuries occurring on or after August 1, 2024, provided the injury was properly reported and documented while the athlete was participating.

This coverage is also excess to other valid and collectible insurance.

Separately, NCAA Division I rules require institutions to provide medical care, including payment of eligible out-of-pocket medical expenses, for athletically related injuries, with qualifying care extending for at least two years following graduation or separation or until the athlete qualifies for the NCAA catastrophic program, whichever occurs first.

Questions Every Student-Athlete Should Ask

Before arriving on campus—or certainly before the competitive season begins—student-athletes and their families should understand how their insurance arrangements actually work.

Useful questions include:

Does my medical insurance specifically cover injuries sustained while participating in intercollegiate athletics?

Are the hospitals, doctors, imaging facilities and specialists around my college within my insurer's network?

What deductible, co-payments or co-insurance could I be responsible for?

Does my college provide secondary athletics accident insurance?

If it does, when does that policy respond?

Who is responsible for submitting an athletics injury claim?

What happens if my primary medical insurance changes during the academic year?

How long after an injury can treatment and claims continue?

What documentation must be completed when an athletics injury occurs?

The NCAA specifically encourages student-athletes and families to understand issues such as athletic-injury coverage, provider networks, deductibles, co-pays and responsibility for expenses that aren't covered.

Documentation Matters

One point that can easily be overlooked is the importance of reporting injuries properly.

An injury that appears relatively minor today could ultimately require significant investigation, rehabilitation or surgery.

For example, eligibility for the NCAA Post-Eligibility Insurance Program requires qualifying injuries to have been reported, documented and on file with the athletics department at the institution where the athlete participated when the injury occurred.

Student-athletes should therefore follow their institution's injury-reporting procedures and make sure sporting injuries are appropriately recorded.

The Bottom Line

Medical insurance for intercollegiate student-athletes is best understood as a coordinated system of coverage rather than a single policy.

Primary medical insurance may provide the first layer of protection.

Institutional secondary or excess athletics insurance may provide another layer for qualifying sporting injuries.

And for NCAA student-athletes facing exceptionally high eligible medical expenses, the NCAA Catastrophic Injury Insurance Program can provide an additional layer once the applicable threshold has been reached.

But the existence of these different layers does not mean that every medical expense will automatically be paid.

The details matter.

Provider networks, deductibles, policy exclusions, claim procedures, institutional policies and the precise circumstances of an injury can all affect how a claim is handled.

For student-athletes—and particularly international student-athletes studying and competing in the United States—understanding those arrangements before an injury happens can make an enormous difference.

At Sports Scholarship Insurance, we believe student-athletes and their families should understand the protection they have in place before they need to use it.

Protecting today. Securing tomorrow.

This article provides general information only and should not be considered insurance, medical or legal advice. Insurance coverage is subject to the terms, conditions, exclusions, limits and eligibility requirements of the relevant policy. NCAA and institutional requirements may change. Student-athletes and families should review the applicable policy documentation and confirm arrangements directly with their institution and insurance provider.