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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William P. Vaughan, Principal
Health Systems Concepts, Inc.
October 1st – 3rd , 2008
Tells you how the patient became eligible for
4th digit Entitlement
premium Part A
9 Covered under Premium Part A
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
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
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.
The End Stage Renal Disease (ESRD) Program
Is Medicare Primary or is Medicare Secondary or….?
An individual under age 65 is entitled to Medicare hospital insurance benefits if all of the following conditions are met:
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.
(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;
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!)
A “non-Medicare” patient is one that at the time a medical service is rendered is not Medicare Eligible or Entitled.
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 is always primary, Medicaid is always secondary.
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.
The Medicare Intermediary/Carrier to contact for MSP determinations is…
1-800-999-1118 (New York)
US Dept of labor (information on Cobra)
US Dept of Health &Human Services