CMS Pub. 100-05, ch. 5, § 30.6

Non-Automobile Medical or No-Fault Insurance

(Rev. 11550; Issued: 08 -12-22; Effective: 10 -13-22; Implementation:10 -13-22)

If injuries are covered under automobile medical or no-fault insurance, and the individual also files a

claim against a third party for injuries suffered in the same accident, a claim determination must first

be made by the automobile medical or no-fault insurer before a claim for Medicare benefits can be

paid. This determination should be made to prevent Medicare from paying primary. Medicare

payments may be made to the extent that payment cannot be made under the automobile medical and

no-fault insurance, subject to recovery if the individual later receives payment from a liability

insurer. The MSP Contractor undertakes the necessary development and updates the CWF.

For example, an individual incurs $20,000 in hospital expenses due to an automobile accident. The

individual receives $5,000 in no-fault insurance benefits toward hospital expenses and has a liability

claim pending. Medicare will not pay benefits for the $5,000 in expenses paid for by the no-fault

insurer, but will pay the remaining $15,000 for the entire hospital stay, if the liability insurer does not

pay promptly, subject to recovery when the liability claim is paid.