How does the Medicare Part A pay the medical bills if it is the secondary insurance?

[compiler]

How does the Medicare Part A pay the medical bills if it is the secondary insurance while the employer's group insurance is the primary insurance? Thank you for your answer.

 

[LeeV]

The primary carrier covers the billing cost according to its plan design and rules. Any remaining amount of unpaid claims, if any, are then submitted to Medicare as the secondary payor. As with the primary carrier, Medicare covers the remaining billing costs according to its plan design.

 

[compiler]

Do you mean the Medicare Part A will pay such as the primary insurance deductible, coinsurance for the hospital bills? Thank you for your reply.

 

[LostDollar]

Do you mean the Medicare Part A will pay such as the primary insurance deductible, coinsurance for the hospital bills? Thank you for your reply.

Caveat, I am NOT an insurance agent.

I am a Medicare Beneficiary, but I have never had to deal with Part A hospital costs.

However, I would advise you to be very, very careful with that assumption.

I don't know for sure how Medicare works in this situation, the search terminology you would want to use is "Coordination of Benefits", but let's use a set of assumptions about Medicare's plan design.

To start, you know, a) that Medicare ONLY covers things it considers to be "medically necessary, and b) that the repricing adjustments Medicare makes on the services it does cover are usually quite nice for the plan holder because they can make substantial reductions in the bill.

Now let's assume an employer plan is primary and Medicare is secondary on a service or services.

First: Medicare may totally disallow any payment for a service because they don't consider it medically necessary, EVEN THOUGH THE EMPLOYER PLAN MAY HAVE MADE A PAYMENT FOR IT.

Second: If Medicare's business plan model is to reprice all the allowed services to Medicare's allowed amounts and then subtract the amount(s) paid by the employer plan, MEDICARE MAY HAVE ZERO PAYMENT OBLIGATION ON BEHALF OF THE MEDICARE BENEFICIARY.

My personal opinion would be you should be running this question by a very experienced IMO Medicare agent advisor.

 

[Special Agent]

It doesn't pay anything for physicians,outpatient services such as surgical services,diagnostic PT,home home health,lab etc-it may help pay towards inpatient facility charges depending on the primary insurance deductible etc.

 

[compiler]

Caveat, I am NOT an insurance agent.

I am a Medicare Beneficiary, but I have never had to deal with Part A hospital costs.

However, I would advise you to be very, very careful with that assumption.

I don't know for sure how Medicare works in this situation, the search terminology you would want to use is "Coordination of Benefits", but let's use a set of assumptions about Medicare's plan design.

To start, you know, a) that Medicare ONLY covers things it considers to be "medically necessary, and b) that the repricing adjustments Medicare makes on the services it does cover are usually quite nice for the plan holder because they can make substantial reductions in the bill.

Now let's assume an employer plan is primary and Medicare payout is secondary on a service or services.

First: Medicare may totally disallow any payment for a service because they don't consider it medically necessary, EVEN THOUGH THE EMPLOYER PLAN MAY HAVE MADE A PAYMENT FOR IT.

Second: If Medicare's business plan model is to reprice all the allowed services to Medicare's allowed amounts and then subtract the amount(s) paid by the employer plan, MEDICARE MAY HAVE ZERO PAYMENT OBLIGATION ON BEHALF OF THE MEDICARE BENEFICIARY.

My personal opinion would be you should be running this question by a very experienced IMO Medicare agent advisor.

Thanks. You are very helpful. Being told the Medicare Part A does not pay the outpatient even the service is received in a hospital but the inpatient/admitted patient. The Medicare payout is very tricky.

 

[somarco]

Medicare Secondary Payer | CMS

Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare. When Medicare began in 1966, it was the primary payer for all claims except for those...

www.cms.gov

 

[somarco]

FWIW, my wife broke her hip a few years ago. She was working FT and covered by her EGH even though she was Medicare eligible.

I advised her to enroll in Part A but delay B until she was ready to retire.

Total bills for her hip surgery, hospital and PT were $85k.

Surprisingly, Medicare as a secondary payer, paid $2300 towards her hospital bill.

The best "free" insurance we have ever had.