Medicare payment

Medicare Payment Guidelines When Secondary To Other Insurance

Circumstances under which Medicare payment may be secondary to other insurance include:

1. Group Health Plan Coverage

* Working Aged;
* Disability (Large Group Health Plan); and
* End Stage Renal Disease;

2. No Fault and / or Other Liability; and

3. Work-Related Illness/Injury:

* Workers’ Compensation;
* Black Lung; and
* Veterans Benefits.

No-Fault Insurance

Medicare is secondary to any no-fault insurance, including all forms of automobile no-fault insurance, automobile medical payments, and non-automobile no-fault insurance. No-fault insurance is a form of insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile regardless of who may have been responsible for causing the accident.

Med-Pay is a form of no-fault insurance even when included in automobile insurance of any type. Payment may not be made under Medicare for otherwise covered items or services to the extent that payment has been made, or can reasonably be expected to be made, for the items or services under no-fault insurance. A conditional Medicare payment may be made if the no-fault insurance has not paid and cannot reasonably be expected to make payment promptly.

Liability Insurance

Medicare is secondary to any liability insurance (e.g., automobile liability insurance and malpractice insurance). Liability insurance means insurance (including a self-insurance plan) that provides payment based on the policyholder’s alleged legal liability for injury or illness or damage to property.

It includes, but is not limited to homeowners’ liability insurance, malpractice insurance, product liability insurance and general casualty insurance. It includes payments under state “wrongful death” statutes that provide payment for medical damages. An entity that engages in a business, trade or profession is considered to be self-insured for liability purposes to the extent that it has not purchased liability insurance.

Please also see “Alternative Billing for Liability Insurance and Charges to Patients”

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