Access the Palmetto GBA MSP Lookup Tool to determine whether Medicare should be the primary or secondary payer.
- Aged Worker - Medicare is the secondary payer when the beneficiary is age 65 or older and the primary employer’s group plan has 20 or more employees
- Disability – Medicare is the secondary payer when the beneficiary is under age 65 and the employer’s group plan has 100 or more employees
- Workers' Compensation – When the Medicare beneficiary states that the illness or injury is work related (regardless of past or current employment) and the Bureau of Workers' Compensation agrees that they are responsible for the illness or injury, Medicare is the secondary payer
- Auto/Liability – When the illness or injury is a result of automobile or liability caused by another party or on another’s property, Medicare is the secondary payer. Remember that subrogation can play a part for two years. This is where Medicare makes conditional payments with the intent of receiving refunds once there is a settlement.
- Veterans Administration – Medicare and VA are equal entities. Therefore, beneficiaries without monthly fee basis cards may choose to see their regular physicians. These claims should be submitted to Part B. When services are rendered in a VA facility, file the claim with VA.
- End-Stage Renal Disease (ESRD) – When the beneficiary is enrolled with Medicare solely due to renal failure, Medicare is secondary for the first 30 months. This is known as the Coordination Period.
- Incarcerated Beneficiary – The Centers for Medicare & Medicaid Services (CMS) will deny claims for beneficiaries who are in custody of a state or local government under the authority of a penal statute at the time the provider rendered the service. This provision was implemented in Regulations 42 CFR 411.4(a) and 411.4(b) respectively.
- Consolidated Omnibus Budget Reconciliation Act (COBRA) – Medicare is the secondary payer to group health coverage only if the coverage is by virtue of current employment status (CES). The COBRA continuation of benefits law requires employers to continue health coverage for employees and dependents of employees who no longer work sufficient hours to qualify for the employer’s health plan. Where the employer is required to provide such coverage, the coverage is considered to be 'by virtue' of the COBRA law, rather than by virtue of 'current employment status.' Therefore, Medicare is primary to such coverage. Medicare is always primary over COBRA, except for a person who is entitled to Medicare based on end-stage renal disease and they are in their 30-month coordination period. In this case, if the person has a COBRA plan, it would be primary until the end of the coordination period.