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Medicare Secondary Payer Issues. William P. Vaughan, Principal Health Systems Concepts, Inc. TFCA Workshop October 1 st – 3 rd , 2008. Questions to Ask. Is Medicare Involved? Is there Group Insurance? Is there Medicaid? Is it “Self Insurance”?. Is Medicare Involved?.

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medicare secondary payer issues

Medicare Secondary Payer Issues

William P. Vaughan, Principal

Health Systems Concepts, Inc.

TFCA Workshop

October 1st – 3rd , 2008

questions to ask
Questions to Ask
  • Is Medicare Involved?
  • Is there Group Insurance?
  • Is there Medicaid?
  • Is it “Self Insurance”?
is medicare involved
Is Medicare Involved?
  • Is the patient Medicare “Eligible”?
  • Is the patient Medicare “Entitled”?
  • Is the patient a Medicare “Beneficiary?
hiqa data indicator codes
HIQA: Data Indicator Codes

Tells you how the patient became eligible for

Medicare

4th digit Entitlement

0 Age

  • Disability
  • ESRD
  • Has or had ESRD, currently Disability
  • Has or had ESRD, currently Age
  • Has or had ESRD and is covered under

premium Part A

9 Covered under Premium Part A

slide5

HIQACRO CWF PART A INQUIRY REPLY PAGE 01 OF 07

IP-REC CN 123456789A NM Doe IT J DB 01011920 SX M IN 00450

PN 040016 APP REAS 1 DATETIME 042502 163112 REQ SNG

DISP-CODE 02 MSG UNCONDITIONAL ACCEPT

CORRECT 123456789A NM IT DB SX

A-ENT 070195 A-TRM 000000 B-ENT 070195 B-TRM 000000 DOD 000000 LRSV 60 LPSY 190

DAYS LEFT FULL-HOSP CO-HOSP FULL-SNF CO-SNF IP-DED BLOOD DOEBA DOLBA

CURRENT 50 30 20 80 000 0 021702 040502

PRIOR 57 30 20 80 000 0 061000 061300

PARTB YR 02 DED-TBM 10000 BLD 3 YR 01 DED-TBM 00000 BLD 3 DI 1003000000

FULL-NAME DOE.JANE.P

HMO CURR ID 00000 OPT 0 ENR 000000 TERM 000000

PER 0 PRIOR ID 00000 OPT 0 ENR 000000 TERM 000000

PART A YR BLD 3

CATASTROPHIC A: DED-TBM BLOOD CO-SNF FULL-SNF DOEBA DOLBA DED-APL

YEAR 89 0056000 03 008 142 000000 000000 0000000

ESRD: CODE-1 EFF DATE CODE-2 EFF DATE

PF1=INQ SCREEN PF3/CLEAR=END PF8=NEXT

easy medicare
“Easy” Medicare

Medicare because of Age – the patient is age 65 or older, worked 40 units, normally with a Medicare Card.

Disability – The patient has worked an adequate number of units and has gone through the 24-month waiting period.

medicare is primary
Medicare is Primary
  • Champus/Tricare
  • Medigap plans
  • Retiree benefits
  • Medicaid
  • Indian Health Services
  • Employer group plans with less than 20 employees when the Medicare entitlement is age and the beneficiary is working aged.
  • Employer group plans with less than 100 employees when the Medicare entitlement is disability
  • Employer group plans (including COBRA) for ESRD patients after the 30 month coordination period
  • COBRA for disabled entitlement
the hard part
The Hard Part

The End Stage Renal Disease (ESRD) Program

Is Medicare Primary or is Medicare Secondary or….?

the hard part1
The Hard Part
  • Is the patient Medicare “Eligible”?
  • Is the patient Medicare “Entitled”?
medicare entitlement
Medicare Entitlement

An individual under age 65 is entitled to Medicare hospital insurance benefits if all of the following conditions are met:

  • (1) he or she is medically determined to have ESRD;
  • (2) he or she is either (i) fully or currently insured under the social security program or would be fully or currently insured if his or her employment (after 1936) as defined under the Railroad Retirement Act were considered employment under the Social Security Act; (ii) entitled to monthly social security or Railroad Retirement benefits or (iii) the spouse or a dependent child of a person who meets the requirements of (i) and (ii) above;
  • (3) he or she has filed an application for Medicare Part A; and
  • (4) he or she has satisfied the waiting period.
dual esrd entitlement
Dual ESRD Entitlement
  • If Medicare was the primary payer prior to the onset of End Stage Renal Disease, Medicare will continue to pay primary during the 30-month coordination period.
  • However, if Medicare was secondary prior to the onset of End Stage Renal Disease, it will continue to pay secondary until the 30-month coordination period has expired.
  • After the 30-month coordination period has expired, Medicare will pay primary regardless of the patient’s employment status.
age and esrd
Age and ESRD
  • John is 69 years old and is retired. He has Medicare due to age. John’s wife works full time for a company with less than 20 employees and has EGHI. John begins dialysis in January 2007. Since Medicare is primary prior to the onset of dialysis, Medicare continues to be the primary payer.
age and esrd1
Age and ESRD
  • Bob is 67 and has Medicare due to age, but is working full time and has EGHI. He begins a chronic course of dialysis in June 2007. Prior to ESRD, Bob’s Medicare was secondary to his EGHI due to his current work status, and will continue to be secondary through the 30 month COB period.
age and esrd2
Age and ESRD
  • Jack retired at age 62 and has EGHI coverage as a retiree. In January 2007 he turned 65 and also received a living renal transplant prior to needing dialysis. The retirement plan must remain primary over Medicare from January 2007 through July 2009…the first 30 months of ESRD. Medicare becomes prime beginning 8-01-09.
disability and esrd
Disability and ESRD
  • Jane has been on SSDI for many years and has Medicare. Her husband works full time for a national company and has LGHI that is primary over her Medicare. Jane became ESRD in August 2006. Because Jane’s Medicare was secondary at the onset of ESRD, it remains secondary through the 30 month cob period.
disability and esrd1
Disability and ESRD
  • Joe is disabled, is on SSDI, and has Medicare. His wife works for a small local company with 6 employees and has group health insurance. Due to the group size, Joe’s Medicare is primary over the group health plan. When he starts dialysis , his Medicare will remain primary because it was primary prior to the onset of ESRD.
  • 30 month COB period does not apply.
esrd coordination of benefits
ESRD Coordination of Benefits

The basic ESRD Coordination of Benefits (COB) rule is, if the patient is Medicare Entitled or a Medicare Beneficiary and has an Employer Group plan, the Employer group plan is primary for the first 30 (33 months if the patient is on “In Center” HemoDialysis) months of ESRD treatment.

regular dialysis
Regular Dialysis

Regular Dialysis

  • Entitlement begins on the first day of the third month after the month in which the individual initiates a regular course of renal dialysis, if the course is maintained throughout the waiting period.
  • Example: If dialysis began in January, entitlement would begin April 1.
self dialysis training
Self-Dialysis Training

Self-Dialysis Training

  • Entitlement would begin on the first day of the month in which a regular course of renal dialysis began if:

(i) Before the end of the waiting period, the individual participates in a self-dialysis training program offered by a participating Medicare Facility that is approved to provide such training;

  • (ii) The patient’s physician has certified that it is reasonable to expect the individual will complete the training program and will self-dialyze on a regular basis; and
  • (iii) The regular course of dialysis is maintained throughout the time that would otherwise be the waiting period (unless it is terminated earlier because the individual dies).
transplant
Transplant

Transplant

  • If the individual receives a transplant, entitlement begins with the first day of the month in which the transplant was performed. However, if the individual is admitted as an inpatient to a hospital that is an approved renal transplantation center or renal dialysis center for procedures preliminary to transplant surgery, entitlement begins first :
    • (i) on the first day of the month in which he or she initially enters the hospital, if the transplant is performed in that month or in either of the next 2 months; or
    • (ii) on the day of the second month before the month of kidney transplantation, if the transplant is delayed more than 2 months after the month of initial hospital stay.
  • Example: if an individual enters the hospital in January, and the transplant is performed in January, February, or March, entitlement would begin January 1. However, if the transplant is performed in April, entitlement would begin February 1.
eligibility
Eligibility
  • A patient that is over age 65 and has worked 40 units.
  • A patient that has worked an “adequate” number of units and is disabled.
  • A patient that is “Entitled” under the ESRD provisions of the Social Security Act but has not yet applied for Benefits.
beneficiary
Beneficiary
  • A patient that has a Medicare Card.
  • A patient that is Medicare Entitled.
important note
IMPORTANT NOTE!!!

A PATIENT THAT HAS EMPLOYER

GROUP INSURANCE AND IS MEDICARE

ENTITLED AND/OR HAS THEIR MEDICARE

CARD IS STILL A MEDICARE BENEFICIARY!!!

THEY ARE NOT A “NON-MEDICARE” PATIENT!

(AND YES, I AM SHOUTING!)

note continued
“Note” Continued

A “non-Medicare” patient is one that at the time a medical service is rendered is not Medicare Eligible or Entitled.

employer group
Employer Group

Where the patient is covered by Employer Group Insurance it means that someone is working and that there is a work history.

If there is a work history, Medicare is probably involved!

medicare medicaid or mcr mcd or medi medi
Medicare Medicaid or MCR/MCD or Medi/Medi

Medicare is always primary, Medicaid is always secondary.

medicare and cobra
Medicare and COBRA
  • COBRA will usually terminate when a beneficiary becomes entitled to Medicare benefits.
  • However, if Medicare if is obtained prior to COBRA, then coverage will not be discontinued.
primary complicating factors
Primary Complicating Factors
  • Patient is in the “pre-entitlement” period
  • Medicare Entitlement or Coverage is through a “relationship”.
  • Retroactivity.
retroactivity
Retroactivity

The patient has 1 year from the ESRD “Entitling” event to apply for Benefits.

The benefits are retroactive to the first of the month of the Entitling event.

information from the pro s
Information From The Pro’s

The Medicare Intermediary/Carrier to contact for MSP determinations is…

1-800-999-1118 (New York)

Other Resources:

US Dept of labor (information on Cobra)

www.dol.gov

US Dept of Health &Human Services

www.cms.hhs.gov

many thanks
Many Thanks!
  • I would like to thank Marcia Fisher and the staff at the Michigan Transplant Center for the clip art, editing and the additional slides that rounded out this presentation.
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