An individual is covered by Medicare and has a chronic kidney disease requiring dialysis. They also have a group health plan through their current employer who has 15 employees. Which plan is typically considered the primary payer for their medical expenses?
- AThe employer's group health plan
- BMedicaid
- CMedicare
- DTheir Medicare Supplement plan
Show answer & explanationAnswer & explanation
Correct answer: C. Medicare
For individuals with End-Stage Renal Disease (ESRD) and a group health plan, there's a special rule. Medicare is secondary during a 30-month coordination period if the employer has 20 or more employees. However, if the employer has fewer than 20 employees (as in this case with 15 employees), Medicare is generally the primary payer from the start for ESRD. Even for non-ESRD conditions, if an employer has fewer than 20 employees, Medicare is typically primary over the group plan.
Why the other options are wrong
- A. The group health plan would be primary only if the employer had 20 or more employees (for ESRD during the 30-month period).
- B. Medicaid is for low-income individuals and does not determine primary/secondary payer between Medicare and a group plan in this context.
- D. A Medicare Supplement plan pays after Original Medicare, so it cannot be the primary payer.
Medicare Primary Payer Rules (ESRD & Small Employer)
Specific rules determining whether Medicare or a group health plan pays first for individuals with End-Stage Renal Disease (ESRD) or when the employer has fewer than 20 employees.
- For ESRD, Medicare is secondary for a 30-month coordination period if the employer has 20+ employees.
- If the employer has fewer than 20 employees, Medicare is primary for ESRD from the start.
- For non-ESRD, if employer has <20 employees, Medicare is typically primary.
Memory trick: Medicare Payer: Size matters for the employer, especially with ESRD.