Understanding When  Medicare Is A Secondary Payer  
                     Understa
nding 
When 
Medicare 
Is A 
Secondar
y Payer
 (MSP)
INTRODUCTION
Defining Medicare Secondary Payer (MSP)
Medicare Secondary Payer (MSP) is the term 
generally used when the Medicare program does 
not have primary payment responsibility i.e., 
when another entity has the responsibility for 
paying before Medicare. The MSP provisions have 
protected Medicare Trust Funds by ensuring that 
Medicare does not pay for items and services that 
certain health insurance or coverage is primarily 
responsible for paying. The MSP provisions apply 
to situations when Medicare is not the 
beneficiary’s primary health insurance coverage. 
Medicare statute and regulations require that all 
entities that bill Medicare for items or services 
rendered to Medicare beneficiaries must 
determine whether Medicare is the primary payer 
for those items or services. Primary payers are 
those that have the primary responsibility for 
paying a claim. Medicare remains the primary 
payer for beneficiaries who are not covered by 
other types of health insurance or coverage. 
Medicare is also the primary payer in certain 
instances, provided several conditions are met.
https://www.medisysdata.com/blog/understandin
g-when-medicare-is-a-secondary-payer-msp/
           When 
Medicare Pays First
● Primary payers must pay a claim first. Medicare 
pays first for patients who don’t have other 
primary insurance or coverage. 
● In certain situations, Medicare pays first when the 
patient has other insurance coverage. Below we 
listed common situations when a patient has 
Medicare, other health plan coverage, and which 
entity pays first (primary payer) and which pays 
second (secondary payer)
https://www.medisysdata.com/blog/understanding-when-medicare-is-a-s
econdary-payer-msp/
Working aged (Medicare beneficiaries 
age 65 or older) and Employer Group 
Health Plan (GHP):
● Individual is age 65 or older, is covered by 
a GHP through current employment or 
spouse’s current employment AND the 
employer has less than 20 employees: 
Medicare pays Primary, GHP pays 
secondary
● Individual is age 65 or older, is covered by 
a GHP through current employment or 
spouse’s current employment AND the 
employer has 20 or more employees (or at 
least one employer is a multi-employer 
group that employs 20 or more 
individuals): GHP pays Primary, Medicare 
pays secondary
https://www.medisysdata.com/blog/understanding-
when-medicare-is-a-secondary-payer-msp/
● Disability and Employer GHP
Individual is disabled, is covered by a GHP 
through his or her own current employment 
(or through a family member’s current 
employment) AND the employer has 100 or 
more employees (or at least one employer 
is a multi-employer group that employs 
100 or more individuals): GHP pays 
Primary, Medicare pays secondary
● End-Stage Renal Disease (ESRD)
Individual has ESRD, is covered by a GHP 
and is in the first 30 months of eligibility or 
entitlement to Medicare: GHP pays Primary, 
Medicare pays secondary during 30-month 
coordination period for ESRD
https://www.medisysdata.com/blog/understandi
ng-when-medicare-is-a-secondary-payer-msp/
Consolidated Omnibus Budget 
Reconciliation Act of 1985 (COBRA)
● Consolidated Omnibus Budget Reconciliation Act 
of 1985 (COBRA) – the law that provides 
continuing coverage of group health benefits to 
employees and their families upon the occurrence 
of certain qualifying events where such coverage 
would otherwise be terminated.
● Individual has ESRD, is covered by COBRA and is 
in the first 30 months of eligibility or entitlement 
to Medicare: COBRA pays Primary, Medicare pays 
secondary during 30-month coordination period 
for ESRD
● Individual is age 65 years or older and covered by 
Medicare & COBRA: Medicare pays Primary, 
COBRA pays secondary
● Individual is disabled and covered by Medicare & 
COBRA: Medicare pays Primary, COBRA pays 
secondary
https://www.medisysdata.com/blog/understanding-wh
en-medicare-is-a-secondary-payer-msp/
About Us
      Medisys Data Solutions is a leading 
medical billing company providing 
complete assistance in medical billing and 
coding. We can assist you in receiving 
accurate insurance reimbursement from 
private and government payers. With our 
services like benefits verification and 
credentialing & enrollment, you can add 
more providers in your practice. To know 
more about our specialty specific medical 
billing and coding services, contact us at 
[email protected]/ 302-261-9187.
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