If I have a Medicare Advantage plan, do I have to reimburse both traditional Medicare and the Medicare Advantage plan?



Question: I am a Florida resident with a Medicare Advantage plan, which is asking for money back from charges paid for injuries I suffered in an auto accident. My auto insurer will reimburse my Medicare Advantage plan from my underinsured motorist settlement. But, can Medicare also ask for reimbursement since it pays my plan to administer the Medicare Advantage program? I have not received any Explanation of Benefits statements from The Centers for Medicare & Medicaid Services, and so far CMS has not advised me they are seeking reimbursement.


Response: The Medicare Part C (Medicare Advantage) Program acts as a replacement for traditional Medicare Parts A and B. Under this program, private insurance companies contract with Medicare to provide Parts A and B coverage under their private insurance policies. By providing this coverage to Medicare entitled individuals, traditional Medicare pays a fixed amount per individual that the private insurer enrolls on to their Medicare Advantage plan.

In terms of reimbursement rights, it is important to make the distinction as to which entity paid the benefits for the injury-related care: traditional Medicare or the Medicare Advantage Plan. As it currently stands, most Medicare Advantage plans claim the same priority right of recovery as traditional Medicare claims under the Medicare Secondary Payer Act. Notwithstanding this, if benefits were provided solely under the Medicare Advantage Plan, the reimbursement obligation would only relate to the Medicare Advantage plan.

In our experience in dealing with Medicare Advantage reimbursement obligations, we always suggest separately putting traditional Medicare on notice of the claim. While the circumstances are rare, there are instances where traditional Medicare may pick up some costs even when an individual is enrolled in a Medicare Advantage plan. Accordingly, in order to avoid any potential negative consequences, we would recommend securing confirmation directly from traditional Medicare that they did pay out any injury-related benefits.

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