Multiple Insurers

20.9 - Multiple Insurers (Rev. 11755, Issued:12-21-22, Effective: 01-23-23, Implementation: 01-23-23) A. More Than One Primary Insurer There may be instances where Medicare is secondary payer to more than one primary insurer (e.g., an individual who is covered under his/her own GHP and under the GHP of an employed spouse or under no-fault insurance). In such cases, the other primary payers will customarily coordinate benefits. If a portion of the charges remains unpaid after the other insurers have paid primary benefits, a secondary Medicare payment may be made. See 42 CFR § 411.24. Coordination of benefits (COB) arrangements between private plans, whether based on State law or private agreements, cannot supersede Federal law that makes Medicare secondary payer to certain GHPs for individuals and spouses age 65 or over. Therefore, where the individual has GHP coverage based on current employment status in addition to GHP coverage as a retiree, Medicare is secondary to the GHP coverage based on current employment status and primary to the GHP coverage based on retirement regardless of the coordination of benefits arrangements between the plans. Where services are covered in part by WC and also under liability or no-fault insurance, or there is primary coverage by a GHP, Medicare is the residual payer only. Accordingly, whenever any primary plan pays in part for provider, physician, or other supplier services and the provider, physician, or other supplier does not accept, and is not obligated to accept the payment as payment in full, the provider, physician, or other supplier ensures that a claim is submitted to any other insurer that is primary to Medicare. B. COB Rules Conflict With MSP Rules COB arrangements between private plans, whether based on State law or private agreements, cannot supersede Federal law that makes Medicare secondary payer to GHPs and LGHPs in certain situations. There are two scenarios to consider. The first scenario is where an individual has dependent GHP coverage that is primary to Medicare (e.g., coverage based on the employment of the individual's spouse) in addition to nondependent coverage that is secondary to Medicare (e.g., coverage based on the individual's retirement).In this instance, Medicare is secondary to the dependent coverage and primary to the nondependent coverage. In other words, the dependent coverage pays first and the nondependent coverage pays second even though under private COB agreements, the nondependent coverage would be expected to pay before the dependent coverage. (See example 2 below.) The second scenario is where a plan's payment would normally be secondary to Medicare but, under COB provisions, the payment is primary to a primary payer under §1862(b) of the Act, the combined payment of both plans constitutes the primary payment to which Medicare is a secondary payer. In other words, both plans pay first. (See example 1 below.) EXAMPLE 1: John Jones, age 75, is a Medicare beneficiary with coverage under Part A and Part B. He retired from the Acme Tool Company in 2021 and received retirement health insurance coverage that is secondary to Medicare. His wife, Mary, age 64, has been employed continuously with the local police department since 1977 and since that time has received coverage for herself and her husband under the department's GHP. The priority of payment for John's medical expenses is as follows: • The GHP will be primary, • Medicare will be secondary, and • The retirement plan will be tertiary payer. EXAMPLE 2: Chris Thomas, age 67, is a Medicare beneficiary with coverage under Part A and Part B. He has been employed continuously by XYZ Bolt Company since 2002 and has GHP coverage through his employer. His wife, Ann, age 62, has been retired from the local police department since 2015 and received retirement health insurance coverage for herself and her husband that is secondary to Medicare. The order of payment for Chris' medical expenses is as follows: • Chris's GHP, based on current employment status is primary payer. • Medicare is secondary payer. • The spouse's retirement plan is the tertiary payer.-