As a “secondary payer,” Medicare is the next in line to pay your medical bills. If you are covered by another insurance plan in addition to Medicare, that insurer is likely to be the primary payer of your medical bills. The primary payer will cover the claim up to his/her limits, and then the secondary payer will attempt to cover any remaining costs (if any). However, this does not mean that Medicare will cover all of the remaining costs, nor will it cover the same services that the primary payer has provided. It is the primary payer who is solely responsible for settling a claim. Medicare continues to be the primary payer for those without other health insurance or coverage. Depending on the circumstances, Medicare may also serve as the primary payer.
PRIMARY VS. SECONDARY PAYER RESPONSIBILITY
Following is a list of some common scenarios in which Medicare and other health insurance or coverage may be utilized, as well as which entity will be the primary or secondary payer in these instances.
Working Age (Medicare beneficiaries 65 and up) and Employer Group Health Plan (GHP)
An individual is 65 or older, has a GHP through current or spouse’s current employment, and the employer has fewer than 20 employees: Medicare pays first, and GHP pays second.
An individual is 65 or older, has a GHP through current employment or a spouse’s current employment, and the employer has 20 or more employees (or at least one employer is a multi-employer group that employs 20 or more individuals): GHP covers primary care, while Medicare covers secondary care.
An individual is 65 or older, self-employed, and covered by a GHP through current employment or a spouse’s current employment, AND the employer employs 20 or more people (or at least one employer is a multi-employer group that employs 20 or more people): GHP covers primary care, while Medicare covers secondary care.
As a “secondary payer,” Medicare is the next in line to pay your medical bills. If you are covered by another insurance plan in addition to Medicare, that insurer is likely to be the primary payer of your medical bills. The primary payer will cover the claim up to his/her limits, and then the secondary payer will attempt to cover any remaining costs (if any). However, this does not mean that Medicare will cover all of the remaining costs, nor will it cover the same services that the primary payer has provided. It is the primary payer who is solely responsible for settling a claim. Medicare continues to be the primary payer for those without other health insurance or coverage. Depending on the circumstances, Medicare may also serve as the primary payer.
PRIMARY VS. SECONDARY PAYER RESPONSIBILITY
Some common scenarios in which Medicare and other health insurance or coverage may be utilized, as well as which entity will be the primary or secondary payer in these instances.
Working Age (Medicare beneficiaries 65 and up) and Employer Group Health Plan (GHP)
When an individual is 65 or older, has a GHP through their current employment or a spouse’s current employment, and the employer has fewer than 20 employees, Medicare will pay first, followed by the GHP.
An individual who is 65 years of age or older and has a GHP through either their employment or that of their spouse, and that employer has 20 or more employees (or a multi-employer group with at least 20 employees): GHP covers primary care, while Medicare covers secondary care.
An individual is disabled, is covered by a GHP through his or her current employment (or through the employment of a family member), AND the employer has 100 or more employees (or at least one employer is a multi-employer group that employs 100 or more individuals): GHP covers primary care, while Medicare covers secondary care.
End-Stage Renal Disease (ESRD) (ESRD)
An individual has ESRD, is covered by a GHP, and is within the first 30 months of Medicare eligibility or entitlement. During a 30-month coordination period for ESRD, GHP pays primary and Medicare pays secondary.
An individual has ESRD, is enrolled in a Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) plan, and is in the first 30 months of Medicare eligibility or entitlement. During the 30-month coordination period for ESRD, COBRA pays first and Medicare pays second.
The 1985 Consolidated Omnibus Budget Reconciliation Act (COBRA)
An individual has ESRD, is covered by COBRA, and is within the first 30 months of Medicare eligibility or entitlement. During the 30-month coordination period for ESRD, COBRA pays first and Medicare pays second.
An individual is 65 years of age or older and is covered by Medicare and COBRA. Medicare pays first, and COBRA pays second.
A person is disabled and is covered by Medicare and COBRA. Medicare pays first, and COBRA pays second.
Health Insurance for Retirees
A person who is 65 or older and has an employer-sponsored retirement plan. Medicare pays first, and retiree coverage pays second.
Liability insurance and no-fault insurance
An individual is eligible for Medicare if he or she was involved in an accident or other situation involving no-fault or liability insurance. Liability insurance or no-fault insurance pays. Medicare pays first for accident or other situation-related health-care services claimed or released, and Medicaid pays second.
Insurance for Workers’ Compensation
Because of a job-related illness or injury, an individual is eligible for Medicare and is covered by Workers’ Compensation. Workers’ Compensation pays first and foremost for health-care items or services related to work-related illness or injury claims. In most cases, Medicare will not pay for an injury or illness/disease that is covered by workers’ compensation. If workers’ compensation denies all or part of a claim on the grounds that it is not covered by workers’ compensation, a claim may be filed with Medicare.
If a claim is not covered by workers’ compensation, Medicare may pay it if it relates to a medical service or product covered by Medicare. Prior to settling a workers’ compensation case, the parties should consider Medicare’s interest in future medical services, as well as whether the settlement will include a Workers’ Compensation Medicare Set-aside Arrangement (WCMSA).
PROVIDERS’ RESPONSIBILITIES UNDER MSP
As a Part A institutional provider (such as a hospital), you must:
Prior to providing hospital services, obtain billing information. It is recommended that you use the CMS questionnaire or a similar type of questionnaire; and
Use the condition and occurrence codes on the claim to send any MSP information to the intermediary.
As a Part B provider (physician or supplier), you must:
To obtain MSP information, follow the proper claim rules, such as group health coverage through employment or non-group health coverage due to an injury or illness.
Inquire with the beneficiary during the visit if he or she is pursuing legal action in connection with the services provided; and
Submit an Explanation of Benefits (EOB) form to the designated carrier, including all relevant MSP information. In addition, when submitting an electronic claim, include all of the fields, loops, and segments required to process an MSP claim.
Managing your practice while keeping an eye on accurate insurance reimbursement can be challenging. WWS can help you manage your entire medical billing process. To learn more about our medical billing services, don’t hesitate to
contact us at +1(302)613-1356 or support@wonderws.com.