CMS Pub. 100-16, ch. mc86c17f, § 70.2

(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)

When a Medicare Cost Plan is the secondary payer to an employer group health plan, the

coordination of benefits occurs in the aggregate through the cost report process. This

process results in a copayment as part of the Medicare cost plan benefit package for

which every enrollee is liable. Therefore, there is no coordination of benefits on a

beneficiary-specific basis that would relieve an enrollee with employer group health plan

coverage of his or her cost sharing obligation under the Medicare cost plan. As a result,

the enrollee remains liable for payment of the Medicare cost plan’s cost sharing

regardless of whether Medicare is primary or secondary. However, under 42 CFR

417.454, which addresses beneficiary financial protection contained in the contract

between the Medicare cost plan and CMS, the Medicare cost plan is responsible for

relieving the beneficiary of responsibility for payment of health care costs other than cost

sharing, and therefore, the Medicare cost plan must relieve the enrollee of his or her

liability under the terms of the employer group health plan.

For example, if the employer group health plan (the primary payer) has a copayment of

$20 and the Medicare cost plan has a copayment of $10 for the service the beneficiary

received, the beneficiary cannot be liable to pay more than the plan copayment of $10.

The Medicare cost plan must absolve the beneficiary of the liability for any amount in

excess of the plan copayment of $10.