2004 REACH National Medicare Training Program Speaker Name
- Slides: 44
2004 REACH National Medicare Training Program Speaker Name Group Name Date 1
Coordination of Benefits Module 5 2
Session Topics • • Overview Other payers Determining who pays first Information sources 3
Session Topics • Overview • Other payers • Determining who pays first • Information sources 4
Overview 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 5
Overview 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 6
Overview 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 7
Overview Group Health Incorporated • For general questions – Contact Group Health Incorporated • Customer Service Department – 1 -800 -999 -1118 – TTY/TDD: 1 -800 -318 -8782 – Visit www. cms. hhs. gov/medicare/cob 8
Overview 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 9
Overview 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 10
Overview 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 11
Overview 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 12
Session Topics ü Overview • Other payers • Determining who pays first • Information sources 13
Other Payers 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 14
Other Payers 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 15
Other Payers 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 16
Session Topics ü Overview ü Other payers • Determining who pays first • Information sources 17
Determining Who Pays First 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 18
Determining Who Pays First 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 19
Determining Who Pays First 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 20
Determining Who Pays First 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 21
Determining Who Pays First 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 22
Determining Who Pays First 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 23
Determining Who Pays First TFL…Enrolling in DEERS • Must have up-to-date information in DEERS – Defense Enrollment Eligibility Reporting System • Contact DEERS – 1 -800 -538 -9552 • Must purchase Medicare Part B 24
Determining Who Pays First 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 25
Determining Who Pays First How TFL Works with Medicare • • Your provider will file a claim with Medicare pays if appropriate Medicare automatically sends claim to TFL payment will automatically be sent 26
Determining Who Pays First 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 – 1 -800 -638 -7072 27
Determining Who Pays First 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 28
Determining Who Pays First 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 29
Determining Who Pays First COBRA Contact Information • COBRA – Your benefits administrator – State department of insurance – Department of Labor • 1 -866 -4 -USA-DOL • www. dol. gov/dol/topic/health-plans/cobra. htm • Medicare – Coordination of Benefits Contractor • 1 -800 -999 -1118 • CMS – 410 -786 -1565 – 1 -877 -267 -2323, extension 6 -1565 30
Determining Who Pays First 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 31
Determining Who Pays First 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 32
Determining Who Pays First 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 33
Determining Who Pays First 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 34
Determining Who Pays First EGHP…ESRD • No employment requirement • Coverage by group health plan of any size • Medicare is secondary payer for 30 -month coordination period 35
Determining Who Pays First 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 36
Determining Who Pays First 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 37
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? 38
The answer is… Yes 39
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 daughter has homeowner’s insurance. She does. Who will be the primary payer? 40
Key Concepts • Medicare can be primary or secondary payer • COB ensures proper payment • Determination can be complicated 41
Session Topics ü Overview ü Other payers ü Determining who pays first • Information sources 42
Information Sources • Medicare Coordination of Benefits – www. cms. hhs. gov/medicare/cob/ • Medicare/TRICARE Benefit Overview – www. tricare. osd. mil/ndaa/medicare. htm • Medicare and Other Health Benefits: Your Guide to Who Pays First – www. medicare. gov/Publications/Pubs/pdf/msp. pdf 43
Thanks for your attention… 44
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