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Last Modified: 1/11/2018 Location: FL, PR, USVI Business: Part A, Part B

Learn how to determine when Medicare is the primary or secondary payer

The information included within the table below is based upon the Medicare Secondary Payer Fact Sheet published by the Centers for Medicare & Medicaid Services (CMS). CMS’ MSP fact sheet external pdf file provides a general overview of the Medicare secondary payer provision for billing staff of providers, physicians, and other suppliers and furnishes guidance regarding whether Medicare is the primary or secondary payer based upon specific situational criteria.

If the patient …
And this condition exists…
Then this program
pays first …
… And this program
pays second
Is age 65 or older, and is covered by a group health plan (GHP) through current employment or spouse’s current employment…
The employer has fewer than 20 employees…
Medicare
GHP
Is age 65 or older, and is covered by a GHP through current employment or spouse’s current employment…
The employer has 20 or more employees, or at least one employer is a multi-employer group that employs 20 or more individuals
GHP
Medicare
Has an employer retirement plan and is age 65 or older…
The patient is entitled to Medicare…
Medicare
Retiree coverage
Is disabled and covered by a GHP through his or her own current employment or through a family member’s current employment…
The employer has less than 100 employees...
Medicare
GHP
Is disabled and covered by a GHP through his or her own current employment or through a family member’s current employment…
The employer has 100 or more employees, or at least one employer is a multi-employer group that employs 100 or more individuals…
GHP
Medicare
Has end-stage renal disease and GHP coverage…
Is in the first 30 months of eligibility or entitlement to Medicare…
GHP
Medicare
Has end-stage renal disease and GHP coverage…
After 30 months…
Medicare
GHP
Has end-stage renal disease and COBRA coverage…
Is in the first 30 months of eligibility or entitlement to Medicare...
COBRA
Medicare
Has end-stage renal disease and COBRA coverage…
After 30 months
Medicare
COBRA
Is covered under Workers’ Compensation because of a job-related illness or injury…
The patient is entitled to Medicare…
Workers’ Compensation (for health care items or services related to job-related illness or injury) claims
Medicare
Has been in an accident or other situation where no-fault or liability insurance is involved…
The patient is entitled to Medicare…
No-fault or liability insurance for accident or other situation related health care services claimed or released
Medicare
Is age 65 or older OR is disabled and covered by Medicare and COBRA…
The patient is entitled to Medicare…
Medicare
COBRA
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.