Understanding When Medicare Is A Secondary Payer (MSP)

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Understanding When Medicare Is A Secondary Payer
(MSP)
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Understanding When Medicare Is A Secondary Payer
(MSP)
Defining Medicare Secondary Payer (MSP) Medicare
Secondary Payer (MSP) is the term generally used
when the Medicare program does not have primary
payment responsibility i.e., when another entity
has the responsibility for paying before
Medicare. The MSP provisions have protected
Medicare Trust Funds by ensuring that Medicare
does not pay for items and services that certain
health insurance or coverage is primarily
responsible for paying. The MSP provisions apply
to situations when Medicare is not the
beneficiarys primary health insurance coverage.
Medicare statute and regulations require that all
entities that bill Medicare for items or services
rendered to Medicare beneficiaries must determine
whether Medicare is the primary payer for those
items or services. Primary payers are those that
have the primary responsibility for paying a
claim. Medicare remains the primary payer for
beneficiaries who are not covered by other types
of health insurance or coverage. Medicare is also
the primary payer in certain instances, provided
several conditions are met. When Medicare Pays
First Primary payers must pay a claim first.
Medicare pays first for patients who dont have
other primary insurance or coverage. In certain
situations, Medicare pays first when the patient
has other insurance coverage. Below we listed
common situations when a patient has Medicare,
other health plan coverage, and which entity pays
first (primary payer) and which pays second
(secondary payer).
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Understanding When Medicare Is A Secondary Payer
(MSP)

• Working aged (Medicare beneficiaries age 65 or
  older) and Employer Group Health Plan (GHP)
• Individual is age 65 or older, is covered by a
  GHP through current employment or spouses
  current employment AND the employer has less than
  20 employees Medicare pays Primary, GHP pays
  secondary
• Individual is age 65 or older, is covered by a
  GHP through current employment or spouses
  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 pays Primary, Medicare pays
  secondary
• Individual is age 65 or older, is self-employed
  and covered by a GHP through current employment
  or spouses 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 pays Primary,
  Medicare pays secondary
• Disability and Employer GHP
• Individual is disabled, is covered by a GHP
  through his or her own current employment (or
  through a family members current employment) 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 pays
  Primary, Medicare pays secondary
• End-Stage Renal Disease (ESRD)
• Individual has ESRD, is covered by a GHP and is
  in the first 30 months of eligibility or
  entitlement to Medicare GHP pays Primary,
  Medicare pays secondary during 30-month
  coordination period for ESRD

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Understanding When Medicare Is A Secondary Payer
(MSP)

• Individual has ESRD, is covered by a Consolidated
  Omnibus Budget Reconciliation Act of 1985 (COBRA
  plan) and is in the first 30 months of
  eligibility or entitlement to Medicare COBRA
  pays Primary, Medicare pays secondary during
  30-month coordination period for ESRD. You can
  also refer to the ESRD page for detailed
  information.
• Consolidated Omnibus Budget Reconciliation Act of
  1985 (COBRA)
• Consolidated Omnibus Budget Reconciliation Act of
  1985 (COBRA) the law that provides continuing
  coverage of group health benefits to employees
  and their families upon the occurrence of certain
  qualifying events where such coverage would
  otherwise be terminated.
• Individual has ESRD, is covered by COBRA and is
  in the first 30 months of eligibility or
  entitlement to Medicare COBRA pays Primary,
  Medicare pays secondary during 30-month
  coordination period for ESRD
• Individual is age 65 years or older and covered
  by Medicare COBRA Medicare pays Primary, COBRA
  pays secondary
• Individual is disabled and covered by Medicare
  COBRA Medicare pays Primary, COBRA pays
  secondary
• Retiree Health Plans
• Individual is age 65 or older and has an employer
  retirement plan Medicare pays Primary, Retiree
  coverage pays secondary

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Understanding When Medicare Is A Secondary Payer
(MSP)
No-fault Insurance and Liability
Insurance Individual is entitled to Medicare and
was in an accident or other situation where
no-fault or liability insurance is involved.
No-fault or Liability Insurance pays Primary for
accident or other situation related health care
services claimed or released, Medicare pays
secondary Workers Compensation
Insurance Individual is entitled to Medicare and
is covered under Workers Compensation because of
a job-related illness or injury Workers
Compensation pays Primary for health care items
or services related to job-related illness or
injury claims. Medicare generally will not pay
for an injury or illness/disease covered by
workers compensation. If all or part of a claim
is denied by workers compensation on the grounds
that it is not covered by workers compensation,
a claim may be filed with Medicare. Medicare may
pay a claim that relates to a medical service or
product covered by Medicare if the claim is not
covered by workers compensation. Prior to
settling a workers compensation case, parties to
the settlement should consider Medicares
interest related to future medical services and
whether the settlement is to include a Workers
Compensation Medicare Set-aside Arrangement
(WCMSA). Medisys Data Solutions is a leading
medical billing company providing complete
billing and coding services for various medical
billing specialties. Our team of expert medical
billers and coders are well versed with Medicare
billing guidelines and various billing scenarios.
We can assist you in receiving accurate Medicare
reimbursement for delivered services. To know
more about our Medicare billing services, contact
us at info_at_medisysdata.com / 302-261-9187
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