When is Medicare the Secondary Payer?

Date:   09/26/2008

In most cases, Medicare is primary. Some of the most common scenarios where Medicare can pay as a secondary are:

• The individual or his/her spouse is currently employed and covered under an employer group health plan as a result of current employment.
• The company has 20 or more employees or participates in a multiple-employer or multi-employer group health plan where at least one employer has 20 or more employees.
• Individual in question is entitled to Medicare as a result of a disability; the company has 100 or more employees, or participates in a multi-employer/multiple-employer group health plan where one employer has 100 or more employees.
• The individual in question is Medicare entitled due to end-stage renal disease. Medicare is the secondary payer to a group health plan until a 30 month coordination period has ended.

Provider Action:

For further explanation on how Medicare pays with other types of insurance, please read:
Medicare Coordination of Benefits, Welcome to the Medicare Secondary Payer and You Page on http://www.cms.hhs.gov/COBGeneralInformation/.

This above information is no substitute for a periodic update of your patient’s insurance information. However, this information should help you gain some understanding of how Medicare determines when they are the primary payer or secondary payer.