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Medicare Secondary Payer and YouMedicare Secondary PayerMedicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about "Coordination of Benefits" when assigning responsibility for first and second payment.) The term "Medicare Secondary Payer" is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the "gaps" in Medicare’s coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program. Precedence of Federal LawFederal law takes precedence over State law and private contracts. Thus, for the categories of people described in the regulations discussed below, Medicare is the secondary payer regardless of state law or plan provisions. These Federal requirements are found in Section 1862(b) of the Social Security Act {42 USC Section 1395y(b)(5)}. Applicable regulations are found at 42 CFR Part 411 (1990). More information on MSP laws and regulations is available through the CMS Laws and Regulations Portal. Responsibilities of Beneficiaries Under MSPAs a beneficiary, we advise you to:
Responsibilities of Providers Under MSPAs a Part A institutional provider (i.e. hospitals), you should:
As a Part B provider (i.e. physicians and suppliers)
Responsibilities of Employers Under MSPAs an employer, you must:
Group Health Plans (GHP)An employer cannot offer, subsidize, or be involved in the arrangement of a Medicare supplement policy where the law makes Medicare the secondary payer. It is considered a group health plan when an individual has health care coverage through their or their spouse’s employment. Even if the employer does not contribute to the premium, but merely collects it and forwards it to the appropriate individual’s insurance company, the GHP policy is the primary payer to Medicare. Responsibilities of Attorneys Under MSPAs an Attorney, you must:
Responsibilities of Insurers Under MSPAs a GHP insurer, you must:
As a Non-GHP Auto/Liability Insurer, you must:
Medicare Secondary Payer (MSP) Claims InvestigationEffective January 8, 2001, the COB Contractor assumed responsibility for virtually all initial MSP development activities formerly performed by Medicare intermediaries and carriers. This means the COB Contractor is charged with ensuring the accuracy and timely update of data populated on Medicare’s eligibility database regarding other health insurance that is primary to Medicare. The COB Contractor also handles MSP-related inquiries, including those seeking general MSP information, but not those related to specific claims or recoveries. The COB Contractor is primarily an information gathering entity. A variety of methods and programs are used to identify situations in which Medicare beneficiaries have other health insurance that is primary to Medicare:
The goal of these MSP information-gathering activities is to identify MSP situations rapidly, thus ensuring correct primary and secondary payments by the responsible party. Providers, physicians, and other suppliers benefit from this activity because the total payments received for services provided to Medicare beneficiaries are greater when Medicare is a secondary payer to a GHP than when Medicare is the primary payer. If you have any questions regarding the COB MSP Claims Investigation process, please contact the COB Customer Service Department toll-free at 1-800-999-1118 or TTY/TDD: 1-800-318-8782 for the hearing and speech impaired. Customer Service Representatives are available to assist you Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays. Last Modified on Friday, September 17, 2004
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Centers for Medicare & Medicaid Services
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