Confusion over Medicare Rules and Exceptions

Part 3, Chapter 9: Medicare and Medicare Related Programs: Medicare Page 8

Continued from Previous Page

If the individual is under 65 and is covered by Medicare as a result of a disability, Medicare represents the beneficiary's secondary insurer if the spouse's company has more than 100 full-time employees. In that case, the spouse's employer-sponsored group health insurance plan represents the beneficiary's primary insurer. However, if the spouse's company has less than 100 full-time employees, Medicare represents the beneficiary's primary insurer.

There are also a variety of exceptions to those rules, as there are with many Medicare rules. For example, if the disability involves ESRD (End-Stage Renal Disease), an entirely different set of rules apply. In addition, Medicare may become the secondary insurer in many cases if a Medicare beneficiary has a disability and is also covered for treatments, services, or medical equipment under workman's compensation, liability insurance, veterans' benefits, or other insurance coverage. To make things even more confusing, all of those rules are subject to change. In fact, there have been recent discussions on the federal level of the possibility of revising the rules that relate to the question of when Medicare becomes the secondary insurer in certain cases.

An enormous amount of chaos results from the complex nature of these rules, particularly for Medicare beneficiaries whose spouses work on a full-time basis and who try desperately to figure out if Medicare is their primary or secondary insurer. As a result of the confusion, Medicare beneficiaries may file their medical claims in the wrong order, with claims going to the secondary insurer before the primary insurer has processed them. It can take months to straighten out the resulting problems. In addition to the frustration that the system causes for beneficiaries, it may also cost both private health insurers and Medicare a great deal of money, as insurance company and Medicare personnel process and re-process the bills.

Continued on Next Page