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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 CMS. CMS’ MSP fact sheet 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.

Patient status Condition First payer Second payer
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