Posted and filed under Compliance, FWA, Healthcare, Payers.

Friend of Advize and healthcare payer expert Dino Kasdagly put together a helpful resource for healthcare professionals looking to quickly refresh their knowledge on Medicare as a Secondary Payer practices.

Below you will find several popular instances in which Medicare benefits are secondary to Group Health Plan (GHP) benefits. 

  • If the documented employer has more than 20 employees, then the GHP is the primary
  • Medicare benefits are secondary to benefits payable under GHPs for people under 65 or over those who have GHP coverage as a result of the current employment status of a spouse of any age with such an employer. (Section 70.2 of this chapter and §10 of Chapter 2 of the Medicare Secondary Payer Manual further defines individuals subject to this limitation on payment.
  • Medicare benefits are secondary to benefits payable under a Group Health Plan for individuals eligible for or entitled to benefits based on ESRD during a period of up to 30 months if Medicare was not the proper primary payer for the individual based on age or disability at the time that this individual became eligible or entitled to Medicare based on ESRD.
  • Medicare benefits are secondary payers to “large group health plans” (LGHP) for individuals under age 65 entitled to Medicare based on disability and whose LGHP coverage is based on the individual’s current employment status or the current employment status of a family member.
  • Medicare benefits are secondary to benefits payable under an LGHP for individuals under age 65 entitled to Medicare based on disability who are covered under an LGHP as a result of the: 
  • Individual’s current employment status with an employer that has 100 employees or more (see chapter 2, §30.3); or 
  • Current employment status of a family member with such an employer.
  • Medicare is secondary to Worker’s Compensation Plans (including black lung benefit programs). Payment under Medicare may not be made for any items and services to the extent that payment has been made or can reasonably be expected to be made for such items or services under a workers’ compensation (WC) law or plan of the United States or any State. If it is determined that Medicare has paid for items or services that can be or could have been paid under WC, the Medicare payment constitutes an overpayment.
  • Medicare is secondary to any no-fault insurance, including all forms of automobile no-fault insurance, automobile medical payments, and non-automobile no-fault insurance.
  • Medicare is secondary to any liability insurance (e.g., automobile liability insurance, and malpractice insurance).

NOTE: When specified conditions are met, the MSP statute prohibits Medicare from making payment where payment has been made or can reasonably be expected to be made by group health plans (GHPs), a workers’ compensation law or plan, liability insurance (including self-insurance), or no-fault insurance. If payment has not been made or cannot be reasonably be expected to be made promptly by workers’ compensation, liability insurance (including self-insurance), or no-fault insurance, Medicare may make conditional payments.

Click here to review detailed guidance directly from CMS.