Coordination of Benefits

300.1 - Coordination of Benefits (Rev. 4, 10-01-01) The Medicare program is usually the primary payer for covered Medicare services provided to Medicare members of a Medicare cost-based HMO/CMP; however, there are six categories of services for which Medicare is the secondary payer if a timely filed claim was submitted to the primary payer. These are: • Services covered by a State or Federal Workers’ Compensation law (WC); • Services covered by no fault insurance; • Services covered by any liability insurance; • Services covered by Employer Group Health Plans (EGHPs) in the case of ESRD beneficiaries during a period of generally 30 months; • Services covered by EGHPs in the case of employed beneficiaries age 65 and over and the spouses age 65 and over, of employed individuals; and • Services covered by Large Group Health Plans (LGHPs) in the case of certain disabled Medicare beneficiaries who are covered by reason of their employment or the employment of a family member. No payment will be made to a cost-based HMO/CMP for services to the extent that Medicare is not the primary payer under the provisions of §1862(b) of the Act. If a Medicare enrollee receives covered services from the cost-based HMO/CMP for which the enrollee is entitled to benefits under one of the preceding categories, the HMO/CMP may charge or authorize a provider that furnished the service to charge: • An insurance carrier, employer, or other entity that is the primary payer for these services; or • The Medicare enrollee, to the extent that he/she has been paid by such a primary payer.