When Does Medicare Act as A Secondary Payer?

Medicare is Federal Health Insurance program of the United States of America. Medicare began in 1965 under the Social Security Administration (SSA) and now been administered by the Centers for Medicare and Medicaid Services (CMS). Medicare aims to provide health insurance not only for Americans aged 65 and older but also to some younger people with disabilities.

Medicare might be the only insurance for most individuals; however, many patients choose to have additional insurance to reduce out-of-pocket expenses. When there are multiple insurances, there are a pre-determined set of criteria that determines which policy act as a Primary Insurance vs. Secondary Insurance. Primary Insurance is the insurer that pays a healthcare bill first, whereas secondary insurance covers the remaining costs, such as coinsurance or copayments.

In majority of instances when a patient has multiple insurances, Medicare is considered primary insurance. However, there are several other instances when it might act as secondary insurance.

Medicare Secondary Payer

Medicare acts as the secondary payer when working with other insurance plans under the following circumstances:

  1. Working Aged Medicare Beneficiaries with GHP: Medicare is acting as Secondary and GHP is acting as Primary when an Individual with 65 or older is covered by a Group Health Plan (GHP) through current employment (OR) Spouse’s current employment, provided the employer has 20 or more employees.
  2. Working disabled with GHP: Medicare is acting as Secondary and GHP is Primary when the individual is disabled, covered by GHP when the employer has 100 or more employees
  3. End-Stage Renal Disease (ESRD): Medicare acts as secondary for the ESRD or COBRA individuals during 30-month coordination period of ESRD when the individual is covered by GHP
  4. No-Fault Insurance and Liability Insurance: When an individual has Medicare and met with an accident or other situation where no-fault or liability insurance is involved. Then Medicare is acting as Secondary and No-Fault insurance is primary
  5. Workers Compensation: For any work-related injuries, WC insurance is acting as primary and Medicare pays as secondary.

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