When is Medicare considered the primary payer for an individual with a group health plan?

• A. If the group has 20 or more enrollees
• B. If the individual is self-employed
• C. If the group has less than 20 employees
• D. Only if the individual is retired

Answer: (C)

Medicare is considered the primary payer for an individual with a group health plan when the group health plan has less than 20 employees. In this scenario, Medicare will pay first for health care services. The rationale behind this is that the size of the employer's group plan determines the coordination of benefits between Medicare and the group health plan. For groups with fewer than 20 employees, Medicare takes precedence because the smaller size indicates that the group plan may not be as robust in terms of coverage options and costs related to workers’ health care as larger employers.

In contrast, for groups with 20 or more employees, the group health plan typically becomes the primary payer, leaving Medicare to provide secondary coverage. This structure is in accordance with the rules set forth by the Centers for Medicare & Medicaid Services (CMS) regarding coordination of benefits. Thus, understanding the employee count of the group health plan is crucial for determining which payer is responsible for handling claims first.