October 25, 2014

When Railroad Medicare pays first or second

Palmetto GBA logoWhen Medicare began in the 1960s, it was the primary payer for all services except those covered by workers compensation. In 1980, Congress enacted provisions to shift costs from the Medicare program to private insurers, when possible.

This legislation stopped Medicare from making payment if the payment had already been made, or would be expected to be made, by group health plans or workers’ compensation plans.

Medicare pays first when:

  • You have retiree insurance (from either you or your spouse’s former employment)
  • You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has less than 20 employees
  • You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has less than 100 employees
  • You’re also receiving Medicaid benefits

If you have group health care plan coverage that is primary to Medicare (pays first), it will continue to do so until it pays up to the limits of its coverage. Then Medicare becomes primary.

Medicare pays second when:

  • You’re 65 or older, have group health plan coverage based on your spouse’s current employment, and that employer has 20 or more employees
  • You’re under 65 and disabled, have group health plan insurance based on your or a family member’s current employer, and that employer has 100 or more employees
  • You have end-stage renal disease (ESRD) and you are in the first 30 months of your Medicare eligibility. Medicare pays first after that.
  • You’re covered by no-fault or liability insurance for any services related to an accident

For a detailed explanation of how Medicare works with other insurance coverage, go to www.medicare.gov/publications and view the booklet “Medicare and Other Health Benefits: Your Guide to Who Pays First.”

Insurance that pays after Medicare is referred to as supplemental insurance. Your retiree coverage may act as supplemental insurance, or you may purchase a Medigap policy from a private insurance company. For information about Medigap policies, visit www.medicare.gov/publications and view the booklet “Choosing a Medigap Policy: A Guide to People with Medicare.”

Medicare works with supplemental insurance companies through a process called “crossover.” Crossover is an automatic claim filing service used by Railroad Medicare and Medicare Part B contractors to send claim information to your supplemental insurance company after Palmetto GBA has processed a Medicare claim for you. This saves you the time of filing a claim with your supplemental insurer.

In order for you to be in the crossover program, you must enroll with your supplemental insurer. Once you have enrolled, Railroad Medicare will receive, on a regular basis from the supplemental insurer, a list of patients in the crossover program. Once the lists are received from the crossover companies, claim information is electronically compared with the list to determine if there is a match.

If there is a match, the information is transferred to the requesting crossover company. The information forwarded to the requesting company is similar to the information provided on a Medicare Summary Notice (MSN). If your name and health insurance claim (HIC) number appear on the list, your claims processed during that month will be forwarded to your supplemental insurer. You may be enrolled in the crossover program with more than one supplemental insurer. You can only enroll in the crossover program through your supplemental insurer, not through Railroad Medicare. Likewise, if you want to stop the crossover program, you must do this through your supplemental insurer.

If your supplemental insurance does not participate in crossover with Medicare, you will be responsible for ensuring your insurance receives information about claims Medicare has processed. Many providers will file claims to your supplemental insurance after Medicare has processed your claim. If you provider will not file to your supplemental insurance, contact the plan to verify what information they will need to process a claim. Many supplemental insurance plans will ask you to send a copy of your MSN. If you need an MSN, you may request one from our customer service unit.

If you have questions about how Medicare paid a claim as primary or secondary, please call our toll-free Customer Service Line at (800) 833-4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. For the hearing impaired, call TTY/TDD at (877) 566-3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours customer service representatives are available.

We encourage you to visit our website at www.PalmettoGBA.com/RR/Me and our Facebook page at www.Facebook.com/MyRRMedicare.