Are there any circumstances under which Medicare will assume the primary payer role when the current primary payer refused to pay for a Medicare covered treatment?

1 answer | Last updated: Oct 03, 2016
A fellow caregiver asked...

I am covered by Medicare A&B as well as by a Medicare supplemental policy. When I retired, my wife's insurance became my primary payer due to her company having a large number of employees. My primary payer (wife's insurance) refuses to cover a recommended cancer therapy. The therapy is a Medicare covered benefit. I can't wait for the open enrollment period in order to drop primary coverage. Are there any circumstances under which Medicare will assume the primary payer role when the current primary payer refused to pay for a Medicare covered treatment?


Expert Answers

Yes, there are circumstances in which Medicare will pay the full Medicare-approved amount for a health care treatment that is not covered by a person's "primary" insurance. The way Medicare has set up the rules regarding coverage when there's employer-based insurance based on current employment (in your case, your wife's company) is that the employer-based insurance company is the "primary" payer and Medicare the "secondary" payer. In most cases, this means that the private insurance will pay its portion of a covered health care service, with Medicare paying only the amounts (deductibles, copayments) that the employer-based insurance does not pay. That's the way things work in 99 percent of cases, because private insurance and Medicare usually cover the same things.

The Medicare rules regarding its coverage as a "secondary" payer provide that Medicare will pay for a Medicare-covered health care service for any amount (up to the total Medicare-approved amount) left unpaid by the primary insurance company. In Medicare's own words in its explanation of Medicare and other insurance, after a medical bill has been submitted to the primary insurer and the insurer has decided how much it will pay, "Medicare will review what your group health plan paid, and pay any additional costs up to the Medicare-approved amounts. If the group health plan didn't pay all of your bill, the doctor or provider should send the bill to Medicare for secondary payment." So, as long as the medical treatment is covered by Medicare, Medicare should pay any "additional costs" even if that means the entire cost.

Your doctor's office should check with Medicare before you begin treatment, to determine whether the specific care you are to receive is, in fact, covered by Medicare. If you or your doctor's office want to speak to Medicare directly about this issue, you or they can call the Medicare Coordination of Benefits Contractor at 1-800-999-1118.