Insurance coverage (including a self-insured plan) that pays for all or part of the medical expenses for injuries sustained in the use of, or occupancy of, an automobile, regardless of who may have been responsible for causing the accident. This insurance is sometimes called “personal injury protection,” “medical payments coverage” or “medical expense coverage.”

Insurance (including a self-insured plan) that provides payment based on legal liability for injuries or illness or damages to property. It includes, but is not limited to, automobile liability insurance, uninsured and underinsured motorist insurance, homeowners liability insurance, malpractice insurance, product liability insurance, and general casualty insurance. It also includes payments under State “wrongful death” statutes that provide payment for medical damages.

A plan under which an entity (or an individual) is authorized by State law to carry its own risk instead of insuring itself with a carrier. “Authorized by State law” means not prohibited by State law. The plan established for the Federal government under the Federal Tort Claims Act is also a self-insured plan.

Insurance under which the policy holder's insurer will pay for damages caused by a motorist who has no automobile liability insurance or who carries less than the amount of insurance required by law, or is underinsured.

Optional liability insurance available in some jurisdictions under which the policyholder's level of protection against losses caused by another is extended to compensate for inadequate coverage in the other party's policy or plan.

Any occurrence or activity that the individual believes resulted in injury or illness for which the individual holds another party liable.

Medicare does not pay for items or services to the extent that payment has been made, or can reasonably be expected to be made promptly, for items or services under an automobile medical or no-fault insurance policy or plan (including a self-insured plan). This means that if a Medicare beneficiary is injured in an automobile accident and benefits are available under an automobile insurance policy to pay for hospital or medical services, Medicare does not pay for the services, except where the automobile insurer does not pay the entire bill. (See 2.) This provision is effective with respect to services related to injuries occurring on or after December 5, 1980.

This provision applies to services necessitated by an automobile accident even if the State no-fault law or private insurance contract stipulates that the automobile benefits are secondary to Medicare's. Therefore, beneficiaries, providers, physicians, and suppliers should file claims with the automobile insurer first whenever there is coverage under an automobile medical or no-fault policy. However, if the automobile insurer contests the claim or there will be substantial delay in its decision, Medicare may pay conditional benefits subject to recoupment if the automobile insurer pays the claim.

If Medicare payments have been made but should not have been because Medicare is secondary under this provision, or if payments were made on a conditional basis, they are subject to recovery.

If the automobile insurer pays in part for the services, e.g., where the amount of benefits available under the insurance policy is exhausted, Medicare secondary payments can be made; that is, Medicare may pay for covered services not paid for by the automobile insurer. The Medicare intermediary or carrier determines the amount of Medicare secondary payment to the provider, physician, supplier, or beneficiary.

Medicare is the primary payer only if the services cannot be reimbursed at all under an individual's automobile medical or no-fault insurance; e.g., the individual's automobile insurance coverage expired or automobile benefits are totally exhausted.

Expenses for which Medicare payment may not be made, because payment has been made or can reasonably be expected to be made under automobile insurance are not counted toward the Part A or Part B deductible amounts or against the number of inpatient care days available to the beneficiary.

Medicare providers, physicians, suppliers or beneficiaries, receiving duplicate payments from Medicare and an automobile insurer must refund the Medicare payment, regardless of which payment was received first and even if the provider has already refunded the automobile insurance payments to the insurer or the beneficiary. If a provider, physician or supplier receives the Medicare payment and the beneficiary is paid for the same services by an automobile insurer, the beneficiary must refund the Medicare payment up to the amount of the insurance payment.