Medicare Secondary Payer Overview. For Employer Groups

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1 Secondary Payer Overview For Employer Groups

2 Welcome As an employer offering a group health plan, you must comply with the Secondary Payer (MSP) statute and regulations (the MSP laws). These laws establish as the secondary payer to group health plan coverage in specified instances of dual health care coverage. They also prohibit discrimination against beneficiaries in the offering of group health plan coverage. The MSP laws are complex and can be confusing to even seasoned health care administrators. This document provides a general overview of what your group needs to know about MSP and related issues. It is purely informational and does not modify your policy or coverage in any way, and should not be construed as legal advice or opinion. For information related to Multiple Employer Group Health Plans, see our Secondary Payer Overview for Multiple Employer Group Health Plans and their Participating Employers document. Frequently asked questions What kind of discrimination does prohibit? The MSP laws require group health plans to offer the same benefits under the same conditions to both individuals age 65 and older and those under 65 with coverage based on current employment status. They also generally prohibit group health plans from taking into account that an enrollee has coverage based on age, disability or end-stage renal disease (ESRD). For instance, a group health plan may not charge -entitled individuals enrolled in the group health plan based on current employment status higher premiums than other enrollees who are not -entitled. In addition, the MSP laws prohibit group health plans from differentiating in the benefits they provide between individuals who have ESRD and others enrolled in the plan, on the basis of the existence of ESRD, the need for renal dialysis or in any other manner. When is a secondary payer? Secondary payer status is determined largely on the basis of eligibility/entitlement. In general, is the secondary payer (and the group health plan is the primary payer) when all of the criteria for one of the following rules are met: The Working Aged Rule is a secondary payer when: The individual is entitled to based on age; The individual has group health plan coverage based on his/her (or a spouse s) current employment status; and The relevant employer has 20 or more employees (see next page). The Disability Rule is a secondary payer when: The individual is entitled to based on disability; The individual has group health plan coverage based on his/her (or a spouse s) current employment status; and The relevant employer has 100 or more employees (see next page). The ESRD Rule is a secondary payer when: The individual is eligible or entitled to based on ESRD; The individual has group health plan coverage (with no size or current employment status requirements); and The individual receives health care services within 30 months of the date of eligibility (the ESRD coordination period ).

3 20 or more employees test To determine if you are subject to the Working Aged Rule, answer this question: Has your company employed 20 or more employees for each working day in each of 20 or more calendar weeks (not necessarily consecutive) in either the current or preceding calendar year? If the answer is yes, then your company has 20 or more employees within the meaning of the MSP laws. 100 or more employees test To determine if you are subject to the Disability Rule, answer this question: Has your company employed at least 100 employees on 50% or more of its regular business days during the previous calendar year? If the answer is yes, then the group health plan is a large group health plan subject to the Disability Rule. How should an employer calculate its total number of employees? As an employer, you must consider the following classes of employees whether or not they have enrolled in the group health plan: Full-time; Part-time; On disability and subject to FICA taxes; Leased employees if they are counted as employees under Internal Revenue Code 414 (n); All employees who are members of an affiliated service group under Internal Revenue Code 414 (m); and All employees who are considered a single employer under Internal Revenue Code 52 (a) or (b). Employer size, not group enrollment, determines s primary or secondary payer status. Employers around the 20- or 100-employee mark should consult their own legal counsel to determine their precise size for MSP purposes. Employers should alert Blue Cross when particular enrollees qualify for an exception from the MSP laws based on employer size (and when such exceptions no longer apply). Use the MSP Change form, available at in the Employer s section, or contact s COB Unit (see next page for address). What does it mean to have current employment status? Under the MSP laws, an individual has current employment status when he or she is actively working for the employer, is the employer, or is associated with the employer in a business relationship (e.g., as a contractor or supplier). The term also includes individuals who are not actively working in certain limited instances (e.g., individuals receiving disability benefits from the employer for up to six months). What MSP rules apply when an individual is eligible or entitled to on more than one basis? If a covered member is eligible or entitled to for more than one reason, the following guidelines generally apply: If eligibility based on ESRD comes first, the ESRD Rule takes precedence. If entitlement based on age or disability comes first, the party paying primary prior to the onset of ESRD continues to pay primary. Do the MSP laws apply to small employers? MSP laws may apply to small employers depending on the reason the individual is eligible or entitled to : Age Employers that employ less than 20 employees are exempt from the working aged provisions of the MSP laws. Disability Employers that employ less than 100 employees are exempt from the disability provisions of the MSP laws. ESRD There are no exemptions for small employers.

4 What do I need to do to take advantage of the small employer health plan exception? If your group health plan is exclusive to your company and your company employs less than 20 employees, the beneficiaries in your health plan are automatically eligible for the small employer exclusion from the Working Aged Rule. It is important, however, that you inform us of your employer size so that we can coordinate benefits properly. This can be done through the initial enrollment application, the annual requests for information or the MSP Change form. If an employer grows, when does the group health plan become the primary payer? For working aged individuals, the group health plan becomes primary on the first day that the employer has 20 or more employees in 20 or more calendar weeks in any given year. Please alert Blue Cross immediately when and if the 20 or more employees threshold is met. For disabled individuals, the group health plan becomes primary January 1 of the year following the year in which the employer meets the 100 or more employees test. If an employer shrinks, when does the group plan become the secondary payer? For working aged individuals, becomes primary on January 1 of the year following the year in which the employer has under 20 employees as determined by the 20 or more employees test. For disabled individuals, becomes primary January 1 of the year following the year in which the employer has under 100 employees as determined by the 100 or more employees test. What is an MSP demand letter? When believes it has mistakenly paid primary, it will send a request for reimbursement to the employer in the form of a demand letter. If you receive a demand letter, please send the correspondence and any other materials received from CMS to Blue Cross as soon as possible so that we can assist in researching and responding to the letter. Mail the relevant materials to the COB Unit (please see our Secondary Payer Demand Letter Overview document for more information). Send correspondence or address questions related to MSP to: COB Unit Blue Cross th St. SW, MS 166 Mountlake Terrace, WA Why is it important to adhere to MSP laws? Non-compliance with the MSP laws may result in serious financial consequences for an employer, including fines and a tax equal to 25 percent of the employer s group health plan expenditures for the calendar year. This document contains general information and should not be construed as either legal advice or opinion. It is not a substitute for consulting the actual MSP laws, CMS guidance relating to such laws and/or legal counsel. Notify Blue Cross of change in employer size Please alert Blue Cross immediately of changes that occur in between annual requests for information if changes affect the proper order of payment under MSP laws. To report changes in employer size, use the MSP Change form located at in the Employers section or send notification to the COB Unit.

5 MSP Laws At-A-Glance How to determine primary and secondary payer status for beneficiaries Step 1: Determine Total Employer Size Step 2: Determine reason for entitlement Step 3: Determine subscriber s employment status Step 4: Determine primary payer prior to ESRD (if applicable) Primary payer for members with both Blue Cross and coverage Age Disability Less than 20 employees ESRD Age and ESRD Disability and ESRD for 30 months, then Age Disability ESRD 20 to 99 employees Age and ESRD for 30 months, then for 30 months, then Disability and ESRD Age Disability 100 or more employees ESRD for 30 months, then Age and ESRD for 30 months, then Disability and ESRD for 30 months, then

6 Find more information online Has your company changed size? s MSP Change form is available at in the Employers section. Received a demand letter? s demand letter brochure is available at in the Employers section. Need more information about MSP laws? More information from CMS about MSP laws is available at: 01_Overview.asp Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association ( )

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