Medicare Secondary Payer - Persons with Medicare

As a Medicare Beneficiary...

• You along with 39 million other Americans are entitles to health care benefits under the Medicare program. When you receive health care from a hospital or see your doctor at the family clinic, present your Medicare card so the provider or physician knows to forward the claim to Medicare. If you have no other health coverage, Medicare is considered the primary payer of your medical claims. In addition, many beneficiaries have Medigap insurance to cover the Medicare deductibles and coinsurance. Medigap insurance is supplemental to Medicare.
• You should be aware Medicare may not always be the primary payer of your medical claims. Federal law established requirements that other insurers must pay prior to Medicare when certain conditions are met and providers are required to submit claims to these insurers before submitting claims to these insurers before submitting claims to Medicare. In these situations, Medicare becomes the secondary payer.

Liability and No-Fault Situations

Liability

• A liability situation occurs when you are involved in an accident, injury, illness, or some other damage, and you choose to pursue damages against the responsible party. Liability insurance is coverage that protects against claims based on negligence, inappropriate action or inaction which results in injury to someone. Medicare is the secondary payer to all types of liability insurance, including automobile liability insurance, uninsured motorist, homeowner's liability insurance, malpractice insurance, product liability insurance, and general casualty insurance.

No-Fault

• A no-fault situation occurs when you are involved in an accident, injury, illness, or some other damage which is covered by no-fault insurance. No-fault insurance is insurance that pays for health care services resulting from injury to you regardless of who is at fault for causing the injury. Medicare is the secondary payer to all types of no-fault insurance, including automobile, homeowners, and commercial plans. No-fault insurance is sometimes called "medical payments coverage", "personal injury protection", or "medical expense coverage".

Health Care Provider Responsibility in Liability or No-Fault Situations:

The Centers for Medicare and Medicaid Services (the federal agency managing Medicare) requires health care providers to investigate if the above situations exist with their patients.

Each time you are admitted to a hospital as an inpatient or receive services at a hospital as an outpatient, the registration clerk will ask specific questions to determine whether a no-fault or liability situation exists. This will help your health care provider determine if Medicare should be the primary payer or the secondary payer. The hospital is required to find out this information in each individual case. Your cooperation is greatly appreciated.

Conditional Medicare Payments in Liability or No-Fault Situation:

Even though Medicare may be the secondary payer in certain situations, often Medicare will pay a claim first if the primary no-fault or liability insurance will not pay the claim within 120 days. Medicare makes this payment so that you will not have to use your own money to pay the bill. This payment is referred to as a conditional payment. Money that Medicare has paid conditionally must be repaid to Medicare when a settlement is reached. Medicare must be repaid within 60 days of the settlement. If Medicare is not repaid within the 60-day timeframe, interest may be assessed on the balance due.

Your Responsibility in Liability or No-Fault Situations

• If you have an injury, illness, or some other damage, and you choose to pursue a claim or a lawsuit against the responsible party, you or your attorney should notify Medicare right away that a claim is being pursued.
• Do not wait until a mediation hearing or settlement to request information regarding the amounts that will be owed back to Medicare (due to Medicare conditional payments) once there is a settlement, judgment, or award. This information takes time to gather.
• You can help save Medicare Trust Fund dollars by telling your health care provider if insurance other than Medicare is responsible for paying your bills.

Other Medicare Secondary Payer Situations:

• You or your spouse are working and you have health insurance through the employer's group health plan
• You are disabled and covered under a family member's employer group health plan
• You have a work related injury or illness
• You are a veteran and your medical expenses are covered by the Department of Veterans' Affairs (VA)
• You suffer from black lung respiratory condition related to coal mining with coverage by the Department of Labor
• You have End Stage Renal Disease (ESRD), a disease which requires a ongoing kidney dialysis or a kidney transplant, have health insurance coverage through an employer's group health plan, and are within the 30-month Medicare coordination period
• Your medical expenses are covered by a federal grant program or by a public health service

Your Responsibility

You can help save Medicare Trust Fund Dollars by telling your health care provider if insurance other than Medicare is responsible for paying your medical bills.

If you notice Medicare has paid a bill that you believe another insurer should have paid or if you have questions about a Medicare Secondary Payer situation, please contact the Medicare Coordination of Benefits Contractor at 1-800-999-1118 or TDD/TYY 1-800-318-8782. If you are a Veteran and have questions as to who is the primary payer, please call us at 1-800-Medicare.