Medicare as a secondary payer

Medicare as a Secondary Payer (MSP)


1.Medicare can be secondary to another insurance plan in the following cases:
2. Patient is above 65 and is still working and is covered by an Employer Group Health Plan (EGHP) or spouse who is above 65 is employed with coverage by an EGHP
3. Disability beneficiaries
4. Automobile no-fault insurance or other liability

5. Patient is covered under workers’ compensation

For individuals of age 65 and above, if either they are working or their spouses are working, Medicare can act as secondary insurance provided the benefits of the coverage with their employer is still valid and the employer has 20 or more employees. If either of these conditions is not satisfied, Medicare remains the primary payer. The employer health plan cannot supplement Medicare coverage.

For disabled beneficiaries who are covered by a large group health plan (an employer with 100 or more employees) as a current employee or as a family member of a current employee, Medicare acts as secondary. When an employee or a member of the employee’s family becomes disabled, the large group health plan is primary.

For automobile accident, fall or other liability, Medicare will make payment on conditional basis. If the liability is settled by the no-fault carrier, then Medicare needs to be reimbursed for the payment made.

Similarly for work-related injuries, Medicare will make payment on conditional basis. The primary responsibility vests with workers compensation and Federal Black Lung carriers. Once they make payment, Medicare’s payment should be refunded.

Medicare is also secondary to an EGHP for self-employed individuals who are former employees if the employer provides coverage for such individuals.

Medicare secondary payer manual

1 comment:

Anonymous said...

When MSP denies a procedure as non payable which was processed by Primary with ded/co-ins, can the ded/co-ins be billed to patient since MR do not cover the procedure? Please advice..

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