Give examples when Medicare is the secondary payer (MSP).

What will be an ideal response?

a. Large-group health plan
If the patient is age 65 or over and covered by a large-group health plan because he or she is currently employed, or has coverage through the employment of a spouse, Medicare is the secondary payer. A large-grouphealth plan is one provided by an employer with more than 100 employees.This means that a large-group health plan is the primary payer for hospital and medical expenses. If the group health plan does not pay all of the expenses, Medicare is billed second. However, upon review of the claim, Medicare will consider only Medicare-covered health care services, and will pay only up to the Medicare-approved amounts.
If the group health plan is provided by an employer with less than 20 employees, Medicare is the primary payer. In addition, the patient may choose to decline the group plan from his own or the spouse’s employer. In this case, Medicare is the primary payer (and will probably be the only insurance the patient has).

b. No-fault and liability insurance
Medicare is the secondary payer where no-fault or liability insurance is applicable. No-fault is insurance that pays for health care services resulting from injury to the patient or damage to property regardless of who is at fault for causing the accident. Examples of types of no-fault insurance include, but are not limited to, automobile insurance, commercial insurance plans, and homeowner’s insurance.Liability insurance is coverage that protects against claims based on negligence, inappropriate action, or inaction that results in injury to someone or damage to property. Examples of liability insurance include, but are not limited to, homeowner’s liability insurance, product liability insurance, automobile liability insurance, malpractice liability insurance, and underinsured motorist liability insurance.

c. Workers’ compensation insurance
Workers’ compensation is insurance that employers are required to carry for employees who get sick or injured on the job. Workers’ compensation pays first on the bills for health care items or services received because of work-related illness or injury. If payment is denied by the state workers’ compensation insurance, Medicare will pay only for Medicare-covered items and services. Medicare should be billed only if the claim is denied or contested by the employer, or if the provider is not required to accept workers’ compensation payment as payment in full. If the claim is contested, a statement for benefits contested must be provided so that Medicare will consider making conditional payment.