Medicare Secondary Payer Understanding the Medicare Secondary Payer Multiple Employer Group Health Plan Exception

Transcription

1 Medicare Secondary Payer Understanding the Medicare Secondary Payer Multiple Employer Group Health Plan Exception For Employer Groups participating in Multiple Employer Group Health Plans

2 Welcome If your company is part of a, special rules apply concerning coordination of benefits with Medicare under the Medicare Secondary Payer (MSP) statute and regulations (the MSP laws). Generally, if a includes one employer with 20 or more employees, the group health plan is the primary payer for all Medicare beneficiaries age 65 or older whose coverage is based on current employment status. This is referred to as the Working Aged Rule. If your company has less than 20 employees, however, your multiple employer group may elect for your Medicareeligible members to be excepted from the Working Aged Rule. This exception, which is referred to in these materials as the multiple employer group health plan exception, permits the group health plan to pay secondary to Medicare with respect to such members. (Please see our Medicare Secondary Payer Overview for Multiple Employer Group Health Plans and their Participating Employers document for more about the MSP laws and calculating employer size.) The 20 or More Employees Test To determine if your company has 20 or more employees for purposes of the MSP statute, answer the following question: Has your company employed 20 or more employees (full-time, part-time and leased) for each working day in 20 or more calendar weeks (not necessarily consecutive) in either the current or the preceding calendar year? If the answer is yes, then your company has 20 or more employees for purposes of the MSP laws and is not eligible for the exception from the Working Aged Rule. Frequently asked questions What is the exception and when is it available? A multiple employer group health plan can request an exception to the Working Aged Rule from the Centers for Medicare & Medicaid Services (CMS) for Medicare beneficiaries enrolled in the plan through employers with fewer than 20 employees. With an exception, the plan pays secondary to Medicare for eligible individuals. How should an employer calculate its total number of employees? As an employer, you must include in your calculation 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 Medicare s primary or secondary payer status. Employers around the 20 employee mark should consult their own legal counsel to determine their precise size for MSP purposes. If at any time after you qualify for an exception from the Working Aged Rule your size grows to 20 or more employees, you must immediately alert your multiple employer group health plan. You may use the MSP Change form, available at in the Employers section, or any other form developed by your multiple employer group health plan for such purpose. Send Premera Blue Cross a copy of any notice you furnish to the multiple employer group concerning change of status. What materials must an employer provide to the multiple employer group to request an exception? To assist your multiple employer group health plan in requesting an MSP exception, provide a letter to your with the following information (see Sample Small Employer Letter ): The employer s name, address and Tax Identification Number (TIN); The name of the insurer, type of coverage and effective date of coverage for the employer-sponsored insurance; Your total number of employees; A statement that you did not (and do not) have 20 or more employees as defined in the MSP Laws (see the 20 or More Employees Test above); and A list identifying those enrollees who are Medicare beneficiaries subject to the exception (see Sample Exhibit). Under CMS policy, only the multiple employer group health plan may request an exception from CMS on your behalf.

3 How does a multiple employer group health plan request an exception? A can request an exception from the MSP Working Aged Rule by sending the following packet of information to the Medicare Coordination of Benefits Contractor, with a copy to Premera Blue Cross: A cover letter from the multiple employer group health plan electing the exception from the Working Aged Rule on behalf of Medicare beneficiaries (and their spouses) working for small employers within that multiple employer group health plan; A copy of the letter(s) described above from each employer for whom the is seeking the exception; A consolidated list compiled by the identifying those members who are Medicare beneficiaries subject to the exception with their social security or health insurance claim numbers (HICs). Will the Multiple Employer Group Health Plan notify us when the exception has been approved by CMS? Yes. The Multiple Employer Group Health Plan is required to notify each employee/spouse for whom the Multiple Employer Group Health Plan is requesting Medicare be the primary payer. immediately of any changes (including new employees who qualify for the exception). For ease, you may use the MSP Change form available at in the Employers section, or any other form generated by your multiple employer group health plan. What do I do if my company grows to have 20 or more employees as defined by the MSP laws? It is your responsibility to notify your of any changes that occur throughout the year which impact the coordination of benefits. Report changes in your group size immediately to the multiple employer group health plan by using the MSP Change form, available at in the Employers section, or any other form generated by your multiple employer group for such purpose. Premera Blue Cross will require multiple employer group health plans to alert Premera regarding changes that affect enrollee status under the MSP laws and certify annually that the exception packet provided to CMS is still accurate. What is a HIC number? What if all employers in the multiple employer group health plan have less than 20 employees as defined by the MSP laws? When all employers in a multiple employer group health plan have less than 20 employees, the Working Aged Rule does not apply. For record-keeping purposes, and to ensure that benefits are coordinated properly, Premera will require multiple employer group health plans that fit within this category to certify at renewal that no participating employer has 20 or more employees. Why is it important to adhere to Medicare Secondary Payer laws? Non-compliance with the MSP laws may result in serious financial consequences for an employer, which may include a fine 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. A HIC number is a number assigned by Medicare that uniquely identifies each Medicare beneficiary. This number can be found on the beneficiary s Medicare card, as illustrated below. What happens if a small employer adds Medicare beneficiaries after an election has been filed? Only individuals specifically listed in an election letter to CMS from the are eligible for the exception. Notify your HIC # SIGN HERE start date

4 Sample Small Employer Letter To be sent by small employers to the for inclusion in the MSP exception request Place on Employer s Letterhead [Date] [Name of MEG] [Address of MEG] RE: MSP Employer Size Attestation Dear [MEG]: [Name of employer] [Tax identification number] is an employer group receiving health insurance coverage through [Name of MEG]. [Name of MEG] receives coverage through Premera Blue Cross. [Name of employer] has been receiving coverage since [insert date of initial coverage]. Under the Medicare Secondary Payer Rules, [Name of MEG] may elect that Medicare pay primary on all claims for health-related services received by a Medicare beneficiary who is an employee of a small employer that obtains health insurance coverage through a multiple employer group, or that employee s spouse. [Name of employer] states that it currently has [Number] employees. Moreover, [Name of employer] hereby attests that it does not (and did not) employ 20 or more employees for each working day in each of 20 or more calendar weeks in the current and preceding calendar year. For purposes of these calculations, the total employee count includes all full-time, part-time, disabled, and leased employees if they would be counted as employees under the Internal Revenue Code 414(m). Attached also please find a complete list of all Medicare beneficiaries and their spouses who are currently employed by [name of employer group] and receiving health insurance coverage through [name of MEG], including each person s name, date of birth and Social Security or health insurance claim (HIC) number. Sincerely, [Name] [Title] Small employer group means an employer that does not have 20 or more individuals in current employment status for each working day in each of 20 or more calendar weeks in the current calendar year and the preceding calendar year. See 42 U.S.C. 1395y(b)(1)(A)(iii).

5 Sample Exhibit To be sent by small employers to the for submission in connection with the MSP exception request Exhibit: Individuals Eligible for Exception from Working Aged Provisions of Medicare Secondary Payer Laws Set forth below is a list of Medicare beneficiaries age 65 and over who are receiving health care coverage through [insert name of MEG] based on their (or their spouse s) current employment status with [name of employer]. Name Date of Birth Social Security or Medicare Health Insurance Claim Number 5

6 Find more information online Premera s MSP Change form available at in the employers section. Premera s Medicare Secondary Payer Overview brochure available at in the employers section. More information from CMS about MSP laws available at: Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association ( )