HealthFlex IRS/SSA/CMS Data Match Questionnaire Information
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1 1901 Chestnut Avenue Glenview, Illinois wespath.org HealthFlex IRS/SSA/CMS Data Match Questionnaire Information Organizations participating in the Hospitalization and Medical Expense Program ( HealthFlex ) periodically receive requests from the Centers for Medicare and Medicaid Services ( CMS ) to complete an IRS/SSA/CMS Data Match Questionnaire ( Questionnaire ). CMS reviews the responses to ensure that Medicare does not pay claims that should be properly paid by employer health plans. The online Questionnaire is divided into four parts. There is also an instruction guide ( Data Match Instructions ) available online. You should read the Data Match Instructions before attempting to complete the Questionnaire. This publication is designed to provide you with additional information and to assist you in completing the Questionnaire. Wespath Benefits and Investments (Wespath) 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, Wespath 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: Part I: Employer Information To assist you in responding to Part I 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 plans 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. (HealthFlex is considered a multi-employer group health plan) 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.
2 IRS/SSA/CMS Data Match Questionnaire Information (cont.) Question 5: In the following years, did your organization participate in a multi or multiple employer group health plans 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. Part II: Group Health Plan Information You are only required to complete Part II if you answered YES to any year to Question 2, 3, 4, or 5 in Part I. Part II of the Questionnaire will require health coverage information for specific Medicare-eligible employees and/or their spouses identified in Part III. To complete Part II of the Questionnaire, enter the requested information for the group health plans in which the individuals listed in Part III were covered. You only need to provide information for the time periods indicated. Note: The Group Health Plan Identification Number or code should be left blank. To complete Part II of the Questionnaire, refer to the tables on the following pages. The tables provide plan information for the plan year(s) specified at the top of each table.
3 Prior to December 31, 2004 Plan Type Name of Plan 1 Number (TIN) HealthFlex (HMEP) Leave blank 1201 Davis Street Evanston, IL United Health Care (HMEP UHC) (before ) Columbus Boulevard CIGNA HealthCare (HMEP CIGNA) (on or after ) CIGNA Rx BIN number: Rx PCN number: Rx Group number: P.O. Box 2100 Bourbonnais, IL P.O. Box Houston, TX Northern Region (HMEP BCBS FL) P.O. Box Jacksonville, FL Central East Region (HMEP BCBS FL) Maguire Boulevard Suite 200 Orlando, FL Central West Region (HMEP BCBS FL) Eisenhower Boulevard Suite 200 Tampa, FL Southern Region (HMEP BCBS FL) NW 33 rd Street Suite 100 Miami, FL Capital Health Plan (HMEP Capital) P.O. Box Tallahassee, FL MVP Healthcare, Inc. (HMEP MVP) GPO Box New York, NY
4 Numbers/es January 1, 2005 December 31, 2007 Plan Type Name of Plan 1 Number (TIN) HealthFlex (HMEP) Leave blank 1201 Davis Street Evanston, IL E. Randolph Chicago, IL United HealthCare Insurance Company (HMEP UHC) Columbus Blvd. Northern Region (HMEP BCBS FL) P.O. Box Jacksonville, FL Central East Region (HMEP BCBS FL) Maguire Boulevard Suite 200 Orlando, FL Central West Region (HMEP BCBS FL) Eisenhower Boulevard Suite 200 Tampa, FL Southern Region (HMEP BCBS FL) NW 33 rd Street Suite 100 Miami, FL Capital Health Plan (HMEP Capital) P.O. Box Tallahassee, FL MVP Healthcare, Inc. (HMEP MVP) P.O. Box New York, NY
5 Numbers/es January 1, 2008 December 31, 2008 Plan Type Name of Plan 1 Number (TIN) HealthFlex (HMEP) Leave blank 1201 Davis Street Evanston, IL United HealthCare Insurance Company (HMEP UHC) E. Randolph Chicago, IL Columbus Blvd. Medco (HMEP Rx Medco) Rx BIN number: Rx PCN number: MEDDPRIME (Medicare Companion Plan participants only) Rx Group number: GBOPRX Medco Direct Claims Medco Prescriptions LLC P.O. Box Lexington, KY PacifiCare Secure Horizons (HMEP PacifiCare) MVP Healthcare, Inc. (HMEP MVP) PacifiCare/UHC-Claims Processing M/S AZ E. Hilton Ave Phoenix, AZ P.O. Box 2207 Schenectady, NY
6 Numbers/es January 1, 2009 December 31, 2009 Plan Type Name of Plan 1 Number (TIN) HealthFlex (HMEP) Leave blank 1201 Davis Street Evanston, IL P.O. Box Chicago, IL United HealthCare Insurance Company (HMEP UHC) Columbus Blvd. Medco (HMEP Rx Medco) Rx BIN number: Rx PCN number: MEDDPRIME (Medicare Companion Plan participants only) Rx Group number: GBOPRX Medco Direct Claims Medco Prescriptions LLC P.O. Box Lexington, KY PacifiCare Secure Horizons (HMEP PacifiCare) PacifiCare/UHC-Claims Processing M/S AZ E. Hilton Ave Phoenix, AZ
7 Numbers/es January 1, 2010 December 31, 2013 Plan Type Name of Plan 1 Number (TIN) HealthFlex (HMEP) Leave blank 1901 Chestnut Avenue Glenview, IL P.O. Box Chicago, IL United HealthCare Insurance Company (HMEP UHC) Columbus Blvd. Medco (before 1/1/2013) (HMEP Rx Medco) Medco Direct Claims Medco Prescriptions LLC P.O. Box Lexington, KY Express Scripts (on or after 1/1/2013) (HMEP Rx ESI) Rx BIN number: Rx PCN number: MEDDPRIME (Medicare Companion Plan participants only) Rx Group number: GBOPRX Express Scripts P.O. Box Lexington, KY PacifiCare Secure Horizons (before 1/1/2014) (HMEP PacifiCare) PacifiCare/UHC-Claims Processing M/S AZ E. Hilton Ave Phoenix, AZ
8 Numbers/es Beginning January 1, 2014 Plan Type Name of Plan 1 Number (TIN) HealthFlex (HMEP) Leave blank 1901 Chestnut Avenue Glenview, IL P.O. Box Chicago, IL United HealthCare Insurance Company (HMEP UHC) Columbus Blvd. OptumRx (HMEP Rx Optum) Rx BIN number: Rx PCN number: IRX Rx Group number: GBOP OptumRx P.O. Box Irving, TX /082317
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Percent of Employees Waiving Coverage 27.0% 30.6% 29.1% 23.4% 24.9%
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