Medicare as Secondary Payer

Congress has enacted specific, detailed provisions for determining when a group health plan (GHP) must pay its benefits primary despite available Medicare coverage. Federal laws dictate that, in certain circumstances, GHPs cannot reduce benefits, pay secondary to Medicare, terminate coverage, or otherwise take into account that a patient has Medicare coverage available. Different provisions and restrictions apply based on whether Medicare entitlement is based on age, disability, or end stage renal disease (ESRD). GHPs often misapply these provisions and unknowingly terminate coverage illegally. TGF has frequently resolved these issues simply by educating GHPs on the applicable laws.

When payers persist in offloading their financial obligations onto the federal Medicare program, TGF aggressively pursues the payers. The Medicare as Secondary Payer Act was enacted to reduce government spending and preserve the fiscal integrity of Medicare. To that end, the Act is designed to be construed to make GHPs responsible for payment to the maximum extent possible. TGF vigorously fights GHPs that violate these federal laws and forces GHPs to pay primary and continue coverage consistent with the law.


  • Medicare has specific, detailed provisions for determining when a GHP must pay its benefits primary to available Medicare benefits
  • Federal laws dictate that, in certain circumstances, GHPs cannot reduce benefits, pay secondary to Medicare, or terminate benefits based on availability of Medicare
  • Laws are designed to reduce government spending and preserve the fiscal integrity of the Medicare program
  • GHPs persistently attempt to offload their responsibility on the federal government
  • TGF aggressively and vigorously pursues GHPs that violate these federal laws governing payment of benefits and forces GHPs to pay primary to the maximum extent of the law