| MEDICARE SECONDARY PAYOR FAQ's |
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Medicare coordinates benefits with employer
group health plans. In determination of Coordination of
Benefits (COB), does the count for number of employees
come from the actual number of employees who participate
in the Group Health Plan (GHP) or from the actual number
of full PLUS part-time employees?
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Is entitlement to Medicare based on End
Stage Renal Disease (renal failure) the same as Disability
entitlement?
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When a beneficiary has selected to receive
Medicare services through a restrictive Risk Health Maintenance
Organization (HMO), is a provider obligated to complete
the Medicare Secondary Payor (MSP) Admission Development
Form (ADF)?
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Is a (potential) beneficiary required to
apply for Medicare benefits as soon as they could be eligible
due to ESRD?
Medicare coordinates benefits with employer group health plans.
In determination of Coordination of Benefits (COB), does the
count for number of employees come from the actual number of
employees who participate in the Group Health Plan (GHP) or
from the actual number of full PLUS part-time employees?
The count for number of employees comes from the actual number
of full PLUS part-time employees. For Working Aged (aged 65
and over) beneficiaries, the 20 employee rule applies. For
Disability (age 64 and under) beneficiaries, the 100 employee
rule applies. However, for beneficiaries entitled to Medicare
based on End Stage Renal Disease (ESRD) ONLY, no group size
limit or current working requirement applies.
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Is entitlement to Medicare based on End Stage Renal Disease
(renal failure) the same as Disability entitlement?
No. Medicare has 3 (three) possible reasons for entitlement:
Working Aged, Disability and/or End Stage Renal disease (ESRD).
A beneficiary may be initially entitled based on Disability
(age 64 and under), however upon the 1st (first) day of the
month in which the beneficiary becomes 65, entitlement would
then be based upon Working Aged (age 65 or over). Disability
and Working Aged entitlements are never combined (a.k.a. dual
entitlement).
A Beneficiary may be entitled based solely on ESRD or a combination
of ESRD plus Disability or ESRD plus Working Aged (dual entitlement).
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When a beneficiary has selected to receive Medicare services
through a restrictive Risk Health Maintenance Organization
(HMO), is a provider obligated to complete the Medicare Secondary
Payor (MSP) Admission Development Form (ADF)?
Yes. Medicare does require an MSP ADF be completed
upon EACH admission for service. This requirement also applies
if the beneficiary was not actually seen at the facility, as
in the example of lab work only.
Even though a beneficiary has selected to receive services
through a particular HMO, information regarding GHP coverage,
accident/liability, workers compensation, black lung, etc.
are crucial in determining Medicare's correct primary and/or
secondary payor status.
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Is a (potential) beneficiary required to apply for Medicare
benefits as soon as they could be eligible due to ESRD?
No. A (potential) ESRD beneficiary is not required to apply
for Medicare benefits at the earliest possible date of entitlement.
(There are no regulations requiring any person to apply for
Medicare for any reason.).
An ESRD beneficiary who has a GHP policy, which is primary
over Medicare for the 30 month COB period may chose to delay
Medicare enrollment. This delay is usually due to the Medicare
Part B monthly premium. Some GHP policies have virtually 100%
coverage (as primary) resulting in $0.00 Medicare secondary
payments. However, it is suggested that an ESRD beneficiary
enroll for Medicare 3 months prior to completion of the 30
month COB period. Upon completion of the 30 months, a GHP may
then legitimately begin paying in secondary position and primary
responsibility could fall to the beneficiary, if Medicare entitlement
has not been established.
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