Coordination of Benefits

140.1 - Coordination of Benefits (Rev. 30, 09-05-03) The Medicare program is usually the primary payer for covered Medicare services provided to Medicare members of an HCPP. 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 an HCPP 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 HCPP for which the enrollee is entitled to benefits under one of the preceding categories, the HCPP 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.