REACH National Medicare Training Program Speaker Name Group Name Date

2 Coordination of Benefits Module 5

3 Session Topics Overview Other payers Determining who pays first Information sources

4 Session Topics Overview Other payers Determining who pays first Information sources

5 What Does COB Mean? Determining who pays Medicare claims first Ensuring claims are paid correctly Sending claims data to other insurers Sharing Medicare eligibility data with other primary payers Avoiding duplicate payment Overview

6 Group Health Incorporated Group Health Incorporated (GHI) –Assures that claims are paid correctly the first time, every time –Serves as Medicare Part B and COB Contractor –Centralizes Medicare’s COB activities Overview

7 Group Health Incorporated Identifies available health benefits Coordinates the payment process Provides customer service Assures integrity of Medicare Trust Fund –IRS/SSA/CMS Data Match $350 million saved each year Overview

8 Group Health Incorporated For general questions –Contact Group Health Incorporated Customer Service Department – –TTY/TDD: –Visit Overview

9 Why Is COB Necessary? Prior to 1980, Medicare was primary Federal law changed –Medicare Secondary Payer provisions Certain employers’ insurance pays as primary Primary payment determination based on all available insurance Overview

10 What Is MSP? Medicare Secondary Payer mandates –Correct insurance pays health care bills first –Medicare pays second Identifies other insurance that may pay first –Employer group health plan insurance –Automobile or non-automobile no-fault insurance –Liability insurance –Workers’ compensation –Black lung program Overview

11 Identifying the Appropriate Payer Helps health care providers –Determine whom to bill –Know how to file claims with Medicare Many combinations of coverage possible –Medicare may be primary payer –Medicare may be secondary payer –Medicare may not be a payer Initial Enrollment Questionnaire will help Overview

12 Initial Enrollment Questionnaire Improves the way MSP information is gathered Requests group health insurance information from beneficiaries Five questionnaires specific to MSP Information on eligibility provided by SSA Provides information to Common Working File Overview

13 Session Topics Overview Other payers Determining who pays first Information sources

14 Other Possible Coverage No-fault or liability insurance Workers’ compensation Veterans’ benefits TRICARE for Life (TFL) Federal black lung program COBRA Employer group health plan (EGHP) Retiree plan Other Payers

15 When Medicare is Primary Medicare is only insurance Other source of coverage is –Medigap policy –Medicaid benefits –Retiree benefits –Indian Health Service –TFL –Veterans benefits –COBRA, except for ESRD Other Payers

16 When Medicare is Secondary Injuries where no-fault will cover Condition or injury covered by liability insurance Covered under EGHP –Current employment of beneficiary or spouse Disabled, and covered under LGHP –Current employment of beneficiary or family member ESRD –Covered under GHP of own or family member AND –Within 30-month coordination period Other Payers

17 Session Topics Overview Other payers Determining who pays first Information sources

18 No-Fault Insurance Insurance that pays regardless of who is at fault Medicare is secondary payer Medicare may make conditional primary payment –If claim not paid within 120 days –So you won’t have to use your own money to pay the bill Determining Who Pays First

19 No-Fault Insurance Money must be repaid when settlement is reached Medicare may try to recover conditional payment from you You are responsible for making sure Medicare gets paid Medicare has right of recovery Determining Who Pays First

20 Liability Insurance Protects against claims based on negligence, inappropriate action, or inaction Medicare is secondary payer Health care professionals must attempt to collect before billing Medicare Medicare may make conditional payment –If the liability insurer will not pay within 120 days –Medicare recovers its conditional primary payment Determining Who Pays First

21 Workers’ Compensation Medicare will not pay for workers’ compensation claims If claim denied by workers’ compensation –Claim can be filed for Medicare payment –Medicare may make a conditional payment Determining Who Pays First

22 Department of Veterans Affairs Can get treatment under either program Must choose which benefits to use –Make this choice each time Medicare cannot pay for service covered by VA VA cannot pay for service covered by Medicare Sometimes both Medicare and the VA can pay –VA authorizes services in a non-VA hospital –Doesn’t pay for all services Determining Who Pays First

23 TRICARE for Life Medical coverage known as TFL –Uniformed services retirees –Medicare-eligible –Purchased Medicare Part B Medicare is primary payer Claims filed automatically No monthly premium –Except Medicare Part B Determining Who Pays First

24 TFL…Enrolling in DEERS Must have up-to-date information in DEERS –Defense Enrollment Eligibility Reporting System Contact DEERS – Must purchase Medicare Part B Determining Who Pays First

25 TFL…Enrolling in Medicare DEERS automatically notifies eligible beneficiaries Contact the nearest Social Security office You can enroll in Part B during General Enrollment Period –January 1 to March 31 every year –Coverage will begin July 1 Determining Who Pays First

26 How TFL Works with Medicare Your provider will file a claim with Medicare Medicare pays if appropriate Medicare automatically sends claim to TFL TFL payment will automatically be sent Determining Who Pays First

27 Black Lung Program Lung disease caused by coal mining Services under this program –Considered workers’ compensation claims –Not covered by Medicare Medicare primary for conditions not related to black lung Information –Federal black lung program – Determining Who Pays First

28 COBRA Law requires employers to provide continuation coverage under EGHP –Employers with 20 or more employees –Coverage continues for 18 months Loss of job or reduced work hours Spousal death or getting a divorce Employee/spouse must pay entire premium –Their share plus employer’s –Up to 102% of cost Determining Who Pays First

29 COBRA and Medicare Medicare is usually primary Medicare is secondary in two situations –During ESRD 30-month coordination period –When COBRA coverage is based on bankruptcy Determining Who Pays First

30 COBRA Contact Information COBRA –Your benefits administrator –State department of insurance –Department of Labor USA-DOL Medicare –Coordination of Benefits Contractor CMS – – , extension Determining Who Pays First

31 Employer Group Health Plan Referred to as EGHP Offered by many employers and unions –Current employees –Retirees –Spouse or family member’s employer EGHP –May be fee-for-service plan –May be managed care plan –Can choose to keep or reject Determining Who Pays First

32 EGHP…Working Aged Age 65 or older AND –Working, with coverage provided by EGHP OR –Not working, covered by working spouse’s EGHP Medicare secondary for “working aged” in EGHP Employee or spouse may –Drop EGHP coverage and elect Medicare as primary Determining Who Pays First

33 EGHP…Age 65 or Over Group health plan coverage because of current employment of beneficiary or spouse –Employer has 20 or more employees Self-employed individuals –Covered by a GHP of a firm with 20 or more employees Medicare is secondary payer Determining Who Pays First

34 EGHP…Under 65 and Disabled Group health plan coverage because of current employment –Employer has 100 or more employees –Self-employed and covered by group health plan of employer with 100 or more employees Medicare is secondary payer Determining Who Pays First

35 EGHP…ESRD No employment requirement Coverage by group health plan of any size Medicare is secondary payer for 30-month coordination period Determining Who Pays First

36 ESRD EGHP primary payer for first 30 months Medicare becomes primary after 30 months Separate 30-month coordination period each time you enroll in Medicare based on ESRD Applies only to those with ESRD Determining Who Pays First

37 Retiree Plans Might offer additional benefits –Prescription drug coverage –Routine dental care Get a copy of your plan’s benefits booklet Medicare pays first Retiree coverage will be secondary payer Determining Who Pays First

38 Let’s look at a case study…. Mary works full-time for a company that has 120 employees. She has group health plan coverage for herself and her husband. Her husband has Medicare because of a disability. Will Mary’s group health plan pay first for Mary’s husband, and will Medicare be his secondary payer?

39 The answer is… Yes

40 Let’s look at another case study… Nancy, who is 68 years old, falls and injures herself while visiting her daughter. While at the hospital emergency room, Nancy is asked whether her daughter has homeowner’s insurance. She does. Who will be the primary payer?

41 Key Concepts Medicare can be primary or secondary payer COB ensures proper payment Determination can be complicated

42 Session Topics Overview Other payers Determining who pays first Information sources

43 Information Sources Medicare Coordination of Benefits – Medicare/TRICARE Benefit Overview – Medicare and Other Health Benefits: Your Guide to Who Pays First –

44 Thanks for your attention…