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1 Today s webinar will begin shortly. We are waiting for attendees to log on. Presented by: Tabatha George Phone: (504) tgeorge@ Please remember, employment and benefits law compliance depends on multiple factors particularly those unique to each employer s circumstances. Numerous laws, regulations, interpretations, administrative rulings, court decisions, and other authorities must be specifically evaluated in applying the topics covered by this webinar. The webinar is intended for general-information purposes only. It is not a comprehensive or all-inclusive explanation of the topics or concepts covered by the webinar.

2 When Employers Need to Know About the Medicare Secondary Payer Rules and the CMS Data Match Program Presented by: Tabatha George Phone: (504)

3 Happy Birthday, Medicare!

4 The ABCs (and Ds) of Medicare Medicare was enacted in 1965 under Johnson At that time, 40% of Americans over age 65 were uninsured It is funded by payroll taxes, premiums and general revenue Medicare has Parts A, B, C and D Generally, you are eligible if you: Are 65 or over and a legal resident for at least 5 years Have certain types of disabilities and receive SSDI Have End Stage Renal Disease

5 As it turns out, Medicare is expensive

6 Hello, MSP Rules

7 Medicare Secondary Payer (MSP) Rules MSP Rules added to SSA in 1980 The Medicare, Medicaid, and SCHIP Extension Act of 2007 added MSP mandatory reporting requirements for group health plans

8 Which Employers are Subject to MSP Employers have 20 or more employees, and are thus subject to the MSP Rules, if they have 20 or more full-time and part-time employees for each working day in each of 20 or more calendar weeks in the current or preceding year. Part-time employees count Employees not enrolled in the group health plan count Self-employed individuals participating in the group health plan do not count Once an employer qualifies, it must offer primary coverage for the remainder of that year and throughout the following year, even if the number of employees drops under 20 during that time.

9 Which Employees are Affected Employees who are covered by virtue of current employment status and eligible for Medicare are affected by the MSP rules. Retiree plans COBRA beneficiaries Individuals with End Stage Renal Disease (ESRD)

10 Employer Cannot Take Into Account the Medicare Eligibility of Employee Examples include: Failure to pay primary benefits Offering coverage that is secondary to Medicare Terminating coverage when someone becomes eligible Denying eligibility based on Medicare eligibility Benefit limitations for Medicare eligible participants Higher premiums or longer waiting periods for Medicare-eligible participants

11 When Your Health Plan Must be Primary

12 When Your Health Plan Must be Primary Disabled Individual Individual is disabled and covered by Medicare Covered by group health plan (GHP) through current employer or spouse s employer Employer has 100 or more employees Covered by COBRA GHP pays primary Medicare pays secondary Medicare pays primary COBRA pays secondary

13 When Your Health Plan Must be Primary End-Stage Renal Disease (ESRD) Individual has ESRD and is in the first 30 months of eligibility or entitlement to Medicare Covered by GHP Covered by COBRA Medicare pays secondary during 30-month coordination period for ESRD

14 Same Benefits / Same Conditions MSP Rules also requires a plan to provide a current employee or a current employee's spouse who is age 65 or older with the same benefits, under the same conditions, as are provided to employees and spouses who are under age 65

15 Incentives Prohibited Employers cannot discourage Medicare-eligible employees from enrolling in the health plan Employers are al so prohibited from offering incentives, financial or otherwise

16 Incentives Prohibited Small employers that are not subject to the MSP Rules may be able to reimburse employees for Medicare B or D or supplemental coverage if: The employer health plan does not consist solely of excepted benefits and offers coverage providing minimum value; The employees participating in the Medicare premium reimbursement arrangement are actually enrolled in Medicare Parts A and B; Premium reimbursement under the arrangement is available only to employees who are enrolled in Medicare Parts A and B or Part D; and Reimbursement is limited to Medicare Part B or Part D premiums and premiums for excepted benefits, including supplementary coverage

17 COBRA Under the MSP Rules, COBRA coverage may be terminated early because of Medicare entitlement, which is generally permitted by COBRA. This makes sense because COBRA coverage is not based upon current employment; rather, COBRA coverage is provided, as required by the COBRA statute, to individuals who are no longer entitled to group health coverage based upon current employment. COBRA coverage may also be terminated early because of ESRD-based Medicare entitlement when permitted under COBRA's early termination provisions.

18 SPD Disclosures SPD regulations do not specifically require disclosure of a plan's rules relating to the order of payment for benefits between the plan and Medicare. However, the general requirement to inform participants and beneficiaries of their rights and obligations under the plan and to describe circumstances that may lead to denial or loss of benefits most likely includes disclosure of when a group health plan pays primary and secondary to Medicare.

19 MSP Reporting Requirements Effective January 1, 2009 Insurers for group health plans, or in the case of self-insured plans, TPAs, are required to provide specified information to CMS for individuals who may be eligible for Medicare. If a group health plan is self-insured and self-administered, the reporting requirement falls on the plan administrator or plan fiduciary. Failure to report this information can lead to penalties of $1,000 for each day of non-compliance.

20 Employee Rights under MSP Employees can choose between participating in an employersponsored health plan and Medicare. Employees that elect their group health plan will then have secondary Medicare coverage if they enroll in Medicare. However, if an employee enrolls in Medicare as primary coverage, they cannot also enroll in the group health plan.

21 CMS Data Match Questionnaires

22 Data Match Questionnaires Data Match identifies Medicare beneficiaries who received Medicare benefits with Medicare as the primary payer when Medicare should have been the secondary payer. Employers are required to complete the Data Match report within 30 days of receipt of the Data Match Personal Identification Number (PIN), unless an extension has been requested and approved.

23 Data Match Questionnaires Two submission options are available: Direct Entry and Electronic Media Questionnaire (EMQ). Direct Entry is an option designed for employers with less than 50 workers. This option allows an employer to complete all Data Match questionnaires directly online without downloading or uploading any files. The information is validated for accuracy and completeness as it is entered directly online. The EMQ program is designed to assist larger employers with at least 50 workers. Employers will download a file of the workers on the Secure Web site and then they will upload the data upon completion of the questionnaire.

24 Medicare Monetary Penalties Any entity that makes a prohibited offer or incentive to an employee, whether oral or in writing, is subject to a civil money penalty of up to $5,000 per offer. Failure on the part of a group health plan to fulfill reporting requirements under Section 111 to allow for the coordination of benefits can result in a civil monetary penalty of $1,000 a day for each day of non-compliance for each individual for which the information should have been submitted.

25 IRS Penalties Contributing to a nonconforming group health plan is subject to an additional excise tax imposed by the Internal Revenue Service (IRS) of 25 percent of the employer s or employees group health plan expenses for the relevant year. A nonconforming group health plan is one that: (1) improperly takes into account that an individual is entitled to Medicare; (2) fails to provide the same benefits under the same conditions to employees and spouses age 65 or over as it provides younger employees and spouses; (3) improperly differentiates between individuals with ESRD and others; or (4) fails to refund an erroneous conditional Medicare payment. If an employer reimburses an individual s Medicare premium that is not integrated with a group health plan, it is subject to a $100 IRS penalty, per employee, per day for violating individual premium reimbursement rules under ACA.

26 Common MSP Problems Offering cash incentives to discourage Medicare-eligible employees from participating in the plan Excluding Medicare-eligible dependents Limiting benefits for Medicare-eligible employees Paying secondary to Medicare for disabled employees receiving employer-provided disability benefits for up to six months Failing to pay primary during the first 30 months of an individual's Medicare eligibility or entitlement for end-stage renal disease Allowing employees to pre-tax their Medicare supplement, Medicare Part B, or Medicare Part D premiums under a cafeteria plan Offering to pay all or part of the cost of a Medicare supplement policy for current employees and/or dependents of current employees Failing to register or report required information under the Section 111 reporting requirements

27 Continuing Education Credit HRCI TBD SHRM TBD

28 Final Questions HRCI?? SHRM?? Presented by: Tabatha George Phone: (504)

29 Thank You Presented by: Tabatha George Phone: (504)