When Is Medicare Secondary?

Medicare is a federally funded health insurance program that pays for covered health-care services provided to enrolled members age 65 and older; certain disabled individuals and individuals with permanent kidney failure also qualify. In certain cases, Medicare is a secondary payer when another health insurance is responsible for paying for covered services before Medicare does.

Workers' Compensation

• Medicare is a secondary payer to workers' compensation benefit payments. If an employer contests a worker's claim, Medicare may be billed pending a decision. If a Medicare beneficiary exhausts all appeals under workers' compensation, Medicare is the primary payer. Otherwise, Medicare has the right to recover the conditional primary payment. For example, the Federal Black Lung Program --- a federal workers' compensation program --- must pay for services related to black lung for Medicare beneficiaries entitled to black lung medical benefits. Medicare can be billed for services not covered by the Federal Black Lung Program.

Group Health Plans

• Generally, Medicare is a secondary payer to employer-sponsored group health plans. This rule applies to a Medicare beneficiary who is age 65 and older and who has group health coverage based on his own or his spouse's current employment. The employer must employ at least 20 workers. If the employer has fewer than 20 employees, Medicare pays first. Medicare is also the secondary payer when a Medicare beneficiary who is younger than age 65 and disabled has group health coverage based on his own or a family member's current employment. The employer must employ at least 100 workers. Medicare is the secondary payer for individuals who have end-stage renal disease and group health coverage on any basis. After the first 30 months of eligibility, Medicare becomes the primary payer.

Other Liability Insurance

• Medicare is the secondary payer when automobile liability insurance, uninsured motorist insurance or underinsured motorist insurance is expected to pay for medical services related to an automobile accident. If the primary insurer doesn't pay promptly, the health care provider may bill Medicare, and a conditional payment is made. If payment is later received from the automobile or no-fault insurer, Medicare can recover the payment. Medicare is also the secondary payer for medical claims reported to other liability insurance carriers such as homeowner's insurance, malpractice insurance and general casualty insurance. Medicare may make a conditional payment, which is subject to recovery if the liability insurance carrier later pays.

Department of Veterans Affairs (VA)

• Medicare doesn't pay for the same services covered by VA benefits. However, Medicare can pay for any covered services if the Department of Veterans Affairs authorizes services in a non-VA hospital. In this case, Medicare covers those services not billed to the VA. Because a Medicare beneficiary may also be entitled to VA benefits, it's possible to receive treatment under either program. The VA pays for any medical services you receive at a VA facility or that the VA authorizes in a non-VA facility. Medicare then pays for any covered services for which the VA doesn't pay.