Medicare Secondary Payer (MSP)

• MSP Overview
• Coordination of Benefits (COB) Contractor
• Additional Information
• MSP Lookup Tool

Overview

Medicare Secondary Payer is the term used when Medicare considers payment after a primary insurance company makes their payment determination. You may hear it referred to as "MSP."

The primary payer is required to process and make primary payment on the claim in accordance with the coverage provisions of its contract. If, after the primary payer processes the claim, it does not pay in full for the services, Medicare secondary benefits may be paid for the services.

If a beneficiary is covered under any of the following insurance plans, Medicare would be considered a secondary payer:

• Group Health Insurance (employer has 20 or more employees) - This insurance is provided by an employer to a policyholder who is actively working. Laws affecting this type of insurance include TEFRA, DEFRA, OBRA, COBRA and ESRD.
• Automobile or Liability Insurance - This insurance is applicable in cases where an accident has occurred, whether it is a car accident, a fall or medical malpractice.
• Worker's Compensation - Worker's Compensation covers injuries on the job. The employer's Workmen's Compensation carrier is responsible for the claim first.
• Federal Black Lung Program - This program covers Black Lung claims. Medicare cannot pay claims submitted with a Black Lung Diagnosis code unless a copy of the Explanation of Benefits from the Black Lung Program is submitted showing that no payment was made.
• Veterans Administration - Services rendered at a Veterans Administration facility are not covered under Medicare. If services are rendered at a non-VA facility, Medicare may consider payment for the covered part of the services that the VA didn't pay.
• End Stage Renal Disease (ESRD) - For beneficiaries covered through an employer sponsored health plan through their own or a family member's current or former employment, Medicare is secondary for 30 months for those beneficiaries entitled to Medicare based solely on ESRD from March 1, 1996.

The term "Medicare Secondary Payer" is sometimes confused with "Medicare Supplement." You may hear Medicare Supplement referred to as a "Medigap."

Medigap is a private health insurance policy designed to fill in some of the "gaps" in Medicare's coverage when Medicare is the primary payer.

The following insurance plans are considered a secondary payer to Medicare.

• Supplemental insurance -This is an insurance policy purchased to pay benefits after Medicare has paid the claim as the primary insurer.
• Group Health Insurance (employer has less than 20 employees) - This insurance is provided by an employer to a policyholder who is actively working.

The following insurance plans are selected by the beneficiary in place of original fee-for-service Medicare.

• Medicare Advantage (some of these are referred to as Health Maintenance Organizations or HMOs) - These plans provide care under contract to Medicare. There are several types of Medicare Advantage plans and are available in many parts of the country. Payment cannot be made under fee-for-service Medicare for beneficiaries enrolled in a Medicare Advantage plan.

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Coordination of Benefits (COB) Contractor:

The Coordination of Benefits (COB) Contractor consolidates the activities that support the collection, management, and reporting of other insurance coverage for Medicare beneficiaries. The purposes of the COB program are to identify the health benefits available to a Medicare beneficiary and to coordinate the payment process to prevent mistaken payment of Medicare benefits.

On occasion it may be necessary for the supplier to contact the COB. Some common examples of reasons to contact are below:

• Verify if Medicare is primary or secondary
• Report changes to a beneficiary's health coverage
• Report a beneficiary's accident/injury

You may contact the COB by calling a Customer Service Representative or through Written Correspondence.

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Additional Information

• CMS Laws and Regulations
• CMS Medicare Secondary Payer and You

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MSP Lookup Tool

Is another insurance company or benefits plan involved with the payment of a claim? If so the following application will help you determine if Medicare is the primary or secondary insurer.