HealthFlex IRS/SSA/CMS Data Match Questionnaire Information

Transcription

1 Caring For Those Who Serve 1901 Chestnut Avenue Glenview, Illinois HealthFlex IRS/SSA/CMS Data Match Questionnaire Information Organizations participating in the Hospitalization and Medical Expense Program ( HealthFlex ) periodically receive IRS/SSA/CMS Data Match Questionnaires ( Questionnaire ) from the Centers for Medicare and Medicaid Services ( CMS ). CMS distributes the Questionnaire to ensure that Medicare does not pay claims that should be properly paid by employer health plans. The Questionnaire is divided into four parts and accompanied by an instruction booklet ( Data Match Instructions ). You should read the Data Match Booklet before attempting to complete the Questionnaire. This publication is designed to provide you with additional information and to assist you in completing the Questionnaire. The General Board of Pension and Health Benefits (General Board) recognizes that you may have questions that are not addressed by the Data Match Instructions or this publication. If so, please contact the Conference or Plan Sponsor Liaison assigned to your organization. Your Liaison will work with the HealthFlex team to assist you in completing the Questionnaire. Finally, due to the complexity of the Data Match Instructions and Questionnaire, the General Board recommends that the Annual Conference Benefits Office assist in the completion of any Questionnaire received by any organizations within its sponsored plan, e.g., local churches. For the purposes of completing the Questionnaire, you may need the following information regarding HealthFlex and its third-party administrators: Group health plan identification number or code: None Type of group health plan: Multiple employer health plan with at least one employer who has more than 100 fulltime and/or part-time employees (code H ), including full time, part time, intermittent and/or seasonal employees Number: Leave blank Name of the group health plan: Hospitalization and Medical Expense Program or HMEP Address: 1901 Chestnut Ave., Glenview, IL Additional Information: OPTUMRX (formerly Catamaran) Rx BIN number: Rx PCN number: IRX Rx Group number: GBOP CIGNA Rx BIN number: Rx PCN number: Rx Group number: Page 1 of /082415

2 IRS/SSA/CMS Data Match Questionnaire Information (cont.) To assist you in responding to the Data Match questions in Part 1 of the Questionnaire, please answer Questions 2, 3, 4 & 5 as follows: Question 2: In the following years, did you have 20 or more employees for 20 or more calendar weeks (this includes full time, part time, intermittent and/or seasonal employees)? Answer: The organization should respond yes if it had more than 20 employees or no if it had fewer than 20 employees for the relevant years. Question 3: In the following years, did your organization participate in a multi or multiple employer group health plan in which there was at least one employer who had 20 or more employees for 20 or more calendar weeks (this includes full time, part time, intermittent and/or seasonal employees)? Answer: Yes Question 4: In the following years, did you have 100 or more employees during 50% of your business days (full or part time)? Answer: The organization should respond yes if it had 100 or more employees and no if it had fewer than 100 employees for the relevant years. Question 5: In the following years, did your organization participate in a multi or multiple employer group health plan in which there was at least one employer who had 100 or more employees during 50% of their business days (this includes full time, part time, intermittent and/or seasonal employees)? Answer: Yes Please note: For purposes of the Data Match Questionnaire and the Medicare Secondary Payer Rules, clergy should be included in the employee count of the local church. Page 2 of 8

3 Numbers/es Prior to December 31, 2004 HealthFlex Leave blank 1201 Davis Street Evanston, IL United Health Care (before ) Columbus Boulevard (on or after ) P.O. Box 2100 Bourbonnais, IL United Behavioral Health P.O. Box Houston, TX Northern Region P.O. Box Jacksonville, FL Central East Region 3191 Maguire Boulevard Suite 200 Orlando, FL Central West Region 4904 Eisenhower Boulevard Suite 200 Tampa, FL Southern Region 8400 NW 33 rd Street Suite 100 Miami, FL Capital Health Plan P.O. Box Tallahassee, Fl MVP Healthcare, Inc GPO Box New York, NY Page 3 of 8

4 Numbers/es January 1, 2005 December 31, 2007 HealthFlex Leave blank 1201 Davis Street Evanston, IL Blue Cross Blue Shield of Illinois E. Randolph Chicago, IL United Behavioral Health Northern Region P.O. Box Jacksonville, FL Central East Region 3191 Maguire Boulevard Suite 200 Orlando, FL Central West Region 4904 Eisenhower Boulevard Suite 200 Tampa, FL Southern Region 8400 NW 33 rd Street Suite 100 Miami, FL Capital Health Plan P.O. Box Tallahassee, Fl MVP Healthcare, Inc P.O. Box New York, NY Page 4 of 8

5 Numbers/es January 1, 2008 December 31, 2008 HealthFlex Leave blank 1201 Davis Street Evanston, IL Blue Cross Blue Shield of Illinois E. Randolph Chicago, IL United Behavioral Health Medco Medco Direct Claims Medco Prescriptions LLC P.O. Box CIGNA P.O. Box 5200 Scranton, PA Ceridian Ceridian FSA Claims P.O. Box St. Petersburg, FL PacifiCare Secure Horizons PacifiCare/UHC-Claims Processing M/S AZ E. Hilton Ave Phoenix, AZ MVP Healthcare, Inc P.O. Box 2207 Schenectady, NY VSP VSP Vision Care P.O. Box Sacramento, CA Page 5 of 8

6 Numbers/es January 1, 2009 December 31, 2009 Plan Type HealthFlex Plan Leave blank 1201 Davis Street Evanston, IL Blue Cross Blue Shield of Illinois Medical P.O. Box Chicago, IL Medical United Behavioral Health Behavioral Health Medco Pharmacy Benefit Manager Medco Direct Claims Medco Prescriptions LLC P.O. Box CIGNA Dental P.O. Box 5200 Scranton, PA Ceridian Flexible Spending Account (FSA) Ceridian FSA Claims P.O. Box St. Petersburg, FL PacifiCare Secure Horizons HMO PacifiCare/UHC-Claims Processing M/S AZ E. Hilton Ave Phoenix, AZ VSP Vision VSP Vision Care P.O. Box Sacramento, CA Page 6 of 8

7 Numbers/es Beginning January 1, 2010 Plan Type HealthFlex Plan Leave blank 1901 Chestnut Avenue Glenview, IL Blue Cross Blue Shield of Illinois Medical P.O. Box Chicago, IL Medical United Behavioral Health Behavioral Health Medco (before 1/1/2013) Pharmacy Benefit Manager Medco Direct Claims Medco Prescriptions LLC P.O. Box Express Scripts (on or after 1/1/2013) Pharmacy Benefit Manager Express Scripts P.O. Box CIGNA Dental P.O. Box 5200 Scranton, PA Ceridian (before 9/1/2014) Flexible Spending Account (FSA) Ceridian FSA Claims P.O. Box St. Petersburg, FL PacifiCare Secure Horizons (before 1/1/2014) HMO PacifiCare/UHC-Claims Processing M/S AZ E. Hilton Ave Phoenix, AZ VSP Vision VSP Vision Care P.O. Box Sacramento, CA Page 7 of 8

8 Numbers/es Beginning January 1, 2014 Plan Type HealthFlex Plan Leave blank 1901 Chestnut Avenue Glenview, IL Blue Cross Blue Shield of Illinois Medical P.O. Box Chicago, IL Medical United Behavioral Health Behavioral Health OptumRx Pharmacy Benefit Manager OptumRx P.O. Box Irving, TX CIGNA Dental P.O. Box 5200 Scranton, PA WageWorks (on or after 9/1/2014) Flexible Spending Account (FSA) Claims Administrator P.O. Box VSP Vision VSP Vision Care P.O. Box Sacramento, CA Page 8 of 8