Medicare COB

[Guest bayarea1]

We have a benefit coordination (order of payment/order of turn) situation that would at first read appear to be very simple, yet has proven to be incredibly problematic. CMS/Medicare both live person(s) and website, NAIC through Thompsons, Trilogy, and various other sources have all been tapped to no avail.

COB Scenario:

Employee (under 65) holds group health coverage that is paying secondary to Medicare due to disability (not ESRD) and is not in current employment status.

Spouse has no group coverage but is entitled to Medicare as is over the age of 65.

Question: Who pays prime for spouse?

Our thinking would be Medicare prime due to spouse's individual entitlement and the Employee's inactive status.

Problem: I despirately need regulatory back-up for the correct determination! Any guidance would be greatly appreciated.

[Kirk Maldonado]

Thompson Publishing has a treatise called "Coordination of Benefits Handbook." It costs $349 per year. Their number is (800) 424-2959.

By way of clarification, I have no relationship with Thompson. I just happen to have received a catalog in the mail from them yesterday.

By the way, you have my sympathies. I've done some Coordination of Benefits work over the years, and it is pretty technical stuff.

[Guest bayarea1]

Thank you for your response, but as stated we did utilize Thompsons and the NAIC does not specifically recognize this scenario or provide a general rule to encompass it.