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MSP Situation |
Refer to
Working Aged, Disability or ESRD |
Bill Other
Insurance as Primary |
Bill Medicare
as Primary |
Bill Medicare
as Secondary |
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Person with disability is
under 65 years of age and . . . |
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The beneficiary is not
covered under a large-group health plan and does not have a
spouse. |
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X |
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The beneficiary is covered
under a large-group health plan from a past or present
employer; the employer has fewer than 100 employees;
the beneficiary has no spouse. |
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X |
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The beneficiary is covered
under a large-group health plan from a past employer,
the employer has more than 100 employees; the
beneficiary has no spouse. |
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X |
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The beneficiary is covered
under a large-group health plan from a present employer,
the employer has more than 100 employees; the
beneficiary has no spouse. |
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X |
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X |
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The beneficiary is not
covered under any large-group health plan from a past or
present employer, but the beneficiary has a spouse or
family member who is employed and has the beneficiary
covered under his or her large-group health plan. The spouse’s
or family member’s employer has fewer than 100
employees. |
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X |
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The beneficiary is not
covered under any large-group health plan from a past or
present employer, but the beneficiary has a spouse or family
member who is currently employed and has the
beneficiary covered under his or her large-group health
plan. The spouse’s or family member’s employer has more
than 100 employees. |
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X |
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x |
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The disabled child is covered
under a parent’s contract; the employer has fewer than
100 employees. |
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X |
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The disabled child is covered
under a parent’s contract; the employer has more than
100 employees. |
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X |
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X |
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Refer to
Working Aged, Disability or ESRD |
Bill Other
Insurance as Primary |
Bill Medicare
as Primary |
Bill Medicare
as Secondary |
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End-stage renal disease (ESRD) |
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The beneficiary has coverage
under a current or former employer and is entitled to
Medicare solely on the basis of ESRD. (See the ESRD
guidelines in the Coverage section of this manual.) |
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X |
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X |
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The beneficiary does not have
any employer-group health coverage through self or family
member. |
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X |
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Working Aged Beneficiary is
65 years of age or older and . . . |
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The beneficiary is not
employed and does not have a spouse. |
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X |
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The beneficiary is still
employed and covered under an employer-group health plan;
the employer has fewer than 20 employees. |
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X |
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The beneficiary is still
employed and covered under an employer-group health plan;
the employer has more than 20 employees. |
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X |
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X |
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The beneficiary is not
employed, but has a spouse or family member who is still
employed and has the beneficiary covered under his or her
employer-group health plan; the spouse’s employer has fewer
than 20 employees. |
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X |
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The beneficiary is not
employed, but has a spouse or family member who is still
employed and has the beneficiary covered under his or her
employer-group health plan; the spouse’s employer has more
than 20 employees. |
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X |
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X |
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Medicare does not ususally
pay for services related to the following because the
diagnosis indicates that coverage may be provided by other
insurers:
Auto Accidents (AA), Black Lung (BL), Third Party Liability
(TP), or Workers Compensation (WC)* |
Bill Other
Insurance |
Bill Medicare |
Bill Medicare
as Secondary |
Medicare may
make Conditional Payment |
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The beneficiary is involved
in an AA or WC accident. The provider is billing a claim
with a diagnosis that is related to the injury. |
X |
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X |
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The beneficiary is involved
in an AA or WC accident. The provider is billing a claim
with a diagnosis that is not related to the injury. |
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X |
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The beneficiary is involved
in a TP accident. The provider is billing a claim with a
diagnosis that is related to the injury.** |
X |
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X |
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The beneficiary is involved
in a TP accident. The provider is billing a claim with a
diagnosis that is not related to the injury. |
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X |
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The beneficiary is receiving
Black Lung benefits. The provider is billing a claim with a
diagnosis that is payable under Black Lung. |
X |
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The beneficiary is receiving
Black Lung benefits. The provider is billing a claim with a
diagnosis that is not payable under Black Lung. |
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X |
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*When determining who to bill for a
AA, BL, TP, or WC claim, refer to this table first and then to the
previous table.
**If the provider chooses to bill
the TP insurer or file a lien against the potential settlement, they
cannot also bill Medicare at the same time. If they cannot
collect from the TP promptly, as defined in Definitions, they must
bill Medicare for a conditional payment.
Note: Some
beneficiaries may choose to be covered by Medicare or Veteran’s
Administration (VA) insurance. They cannot be covered by both. For
this reason, if a beneficiary is covered under VA insurance,
Medicare cannot be billed, even as a secondary payer, except for
the copayment amount.
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