CMS Medicare Specialist Benefits Coordination & Secondary Payer Rules 1 — Questions and Answers
Question 1: Which federal law governs Medicare Secondary Payer (MSP) rules and requires certain insurers to pay primary to Medicare?
- The Medicare Secondary Payer Act of 1980 (Correct answer)
- The Social Security Act of 1935
- The Affordable Care Act of 2010
- ERISA of 1974
Correct answer: The Medicare Secondary Payer Act of 1980
The Medicare Secondary Payer Act of 1980 established rules requiring other insurers to pay primary before Medicare in specific circumstances.
Question 2: Under MSP rules, which entity is required to pay primary when a Medicare beneficiary is actively employed and covered by an employer group health plan (EGHP) with 20 or more employees?
- The employer group health plan (Correct answer)
- Medicare Part A
- Medicare Part B
- Medicaid
Correct answer: The employer group health plan
When a Medicare beneficiary is actively employed and the employer has 20+ employees, the EGHP must pay primary and Medicare pays secondary.
Question 3: What is the MSP coordination of benefits rule for a Medicare beneficiary injured in an automobile accident where auto insurance is available?
- Auto insurance pays primary; Medicare may pay secondary for remaining costs (Correct answer)
- Medicare pays primary; auto insurance pays secondary
- Both pay simultaneously with no coordination
- Only Medicare pays; auto insurance is irrelevant
Correct answer: Auto insurance pays primary; Medicare may pay secondary for remaining costs
Auto insurance is a no-fault or liability insurer that must pay primary before Medicare for accident-related medical costs.
Question 4: Under workers' compensation MSP rules, when a Medicare beneficiary has a work-related injury, which payer is primary?
- Workers' compensation (Correct answer)
- Medicare Part A
- Medicare Part B
- The beneficiary's supplemental insurer
Correct answer: Workers' compensation
Workers' compensation is always primary to Medicare for work-related injuries and illnesses.
Question 5: What is a Medicare Set-Aside (MSA) arrangement used for in workers' compensation settlements?
- To protect Medicare's interests by setting aside funds for future Medicare-covered medical expenses related to the injury (Correct answer)
- To pay Medicare premiums on behalf of the beneficiary
- To reimburse Medicare for past payments made on the claim
- To fund Part D prescription drug costs only
Correct answer: To protect Medicare's interests by setting aside funds for future Medicare-covered medical expenses related to the injury
A Medicare Set-Aside protects Medicare's interests by earmarking settlement funds to cover future injury-related medical costs before Medicare pays.
Question 6: When a Medicare beneficiary has End-Stage Renal Disease (ESRD) and is covered by an employer group health plan, how long must the EGHP pay primary before Medicare becomes primary?
- 30 months (Correct answer)
- 12 months
- 6 months
- 24 months
Correct answer: 30 months
For ESRD beneficiaries, the employer group health plan must pay primary for a 30-month coordination period before Medicare ESRD coverage becomes primary.
CMS Medicare Specialist Benefits Coordination & Secondary Payer Rules 1
Which federal law governs Medicare Secondary Payer (MSP) rules and requires certain insurers to pay primary to Medicare?