Disabled Beneficiaries Covered Under a Large Group Health

20.3 - Disabled Beneficiaries Covered Under a Large Group Health Plan (LGHP) (Rev. 11755, Issued:12-21-22, Effective: 01-23-23, Implementation: 01-23-23) Medicare is secondary to LGHPs for individuals under age 65 entitled to Medicare Part A on the basis of disability and whose LGHP coverage is based on the individual’s current employment status or the current employment status of a family member, pursuant to 42 CFR § 411.204. Under the law, a LGHP may not "take into account" that such an individual is eligible for, or receives, Medicare benefits based on disability. The instructions in §10.1 and throughout this manual that are applicable to GHPs are also applicable to LGHPs in processing claims where Medicare is secondary payer for disabled individuals. Where those sections refer to a GHP with 20 or more employees, substitute the term "large group health plan" as defined in Pub. 100-05, Chapter 1, §40, to apply them to disabled individuals. Medicare is secondary to benefits payable under a LGHP for individuals under age 65 entitled to Medicare on the basis of disability who are covered under a LGHP as a result of the: i. Individual's current employment status with an employer that has 100 employees or more (see Pub. 100-05, Chapter 2, §30.3 ); or ii. Current employment status of a family member with such employer (42 CFR 411.200). Special rules apply in the case of multiple employers and multi-employer plans. (See Pub. 100-05, Chapter 2, §30.3.) Medicare is secondary for these Medicare beneficiaries even though the employer policy or plan contains a provision stating that its benefits are secondary to Medicare benefits or otherwise excludes or limits its payments to Medicare beneficiaries. Medicare is secondary payer to LGHP coverage based on an individual’s or family members current employment status.