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 Multiple Employer Group Health Plans

2 Welcome Special rules apply to multiple employer group health plans concerning coordination of benefits under the Medicare Secondary Payer (MSP) statute and regulations (the MSP laws). Generally, if a multiple employer group health plan 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. The multiple employer group health plan may, however, elect for Medicare-eligible members of participating employers with less than 20 employees 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.) 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 does a multiple employer group health plan request an exception? A multiple employer group health plan can request an exception from the MSP Working Aged Rule by sending the following packet of information to the Medicare Coordination of Benefits Contractor (COBC), with a copy to Premera Blue Cross: 1. 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 the small employers within that multiple employer group health plan (see Sample Exception Request Letter ). That includes as exhibits: (1) a list identifying those enrollees who are Medicare beneficiaries subject to the exception (see Sample Small Employer Letter ); (2) the name of the insurer, type of coverage and effective date of the coverage for the employer-sponsored insurance; and (3) the sample letter to be sent to each Medicare beneficiary (see Sample Enrollee Notification Letter ). 2. A letter from each relevant small employer containing; (1) the employer s total number of employees; (2) a statement that the employer did not (and does The 20 or More Employees Test To determine if a company has 20 or more employees for purposes of the MSP laws, answer the following question: Has the 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 the company has 20 or more employees for purposes of the MSP laws and is not eligible for the exception from the Working Aged Rule. See our Medicare Secondary Payer Overview document for more information about how to calculate the total number of employees. not) employ 20 or more employees as defined in the MSP laws (see the 20 or More Employees Test); and (3) The employer s name, address and Tax Identification Number (TIN) (see Sample Small Employer Letter ). 3. The letter from each relevant small employer should also include as an exhibit a list identifying all members who are Medicare beneficiaries subject to the exception (see Sample Exhibit 1 ). We recommend FAXING the above information to: Medicare Coordination of Benefits Attn: Small Employer Exception Request P.O. Box 125 New York, NY Fax: (646) Send a complete copy of all materials to: Medicare COB Unit Premera Blue Cross th St. SW, MS 166 Mountlake Terrace, WA

3 How do I know if my exception request has been accepted? The COBC will provide written confirmation after completion of its review and processing of the request. Approved requests will include a listing of individual(s) whose MSP record(s) and/or Medicare Eligibilty file(s) have been adjusted to reflect Medicare as the primary payer. When will my exception request become effective? Once accepted by the COBC, the date of your request will become the effective date of the exception request, unless the request is dated more than 7 days prior to the receipt date, in which case the receipt date will be used. Should I notify each Medicare beneficiary subject to the election that Medicare will be the primary payer? Yes. It is important to notify in writing each Medicare beneficiary and their covered spouses of the date Medicare will become the primary payer and the multiple employer group health plan the secondary payer. See Sample Enrollee Notification Letter. What happens if a small employer adds Medicare beneficiaries after an election has been filed? Only individuals specifically listed in an exception request to CMS from the multiple employer group are eligible for the exception. Each time a new Medicare beneficiary qualifies for the exception (either as the employee of a company that now meets the exception for the first time or as a new employee of an existing small employer), you must update your exception request (following the steps on the previous page) to except this individual from the Working Aged Rule. It is important that you provide Premera Blue Cross with a copy of any updated exception request submitted to the COBC. What happens if a company grows to have 20 or more employees as defined by the MSP laws? The employer group should report changes in group size immediately to the multiple employer group health plan. The multiple employer group health plan should report changes to Premera Blue Cross so that any necessary adjustments to coordination of benefits can be made. Use the MSP Change form, available at in the Employers section, to report changes to Premera. The multiple employer group health plan may allow employers to use the MSP Change form, or any other form it chooses, to report such changes. A copy of such notification form should be provided to Premera, along with any updated exception materials submitted to the COBC. 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. After the multiple employer group health plan has requested an exception, does additional information need to be provided to Premera? It is the multiple employer group health plan s responsibility to notify Premera of any changes that occur throughout the year which impact the coordination of benefits. Premera will also require multiple employer group health plans to certify annually that the exception request provided to CMS is still accurate and complete. 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.

4 Sample Exception Request Letter Cover letter to be sent to CMS by the multiple employer group health plan Place on Multiple Employer Group Health Plan s Letterhead [Date] Medicare Coordination of Benefits Attn: Small Employer Exception Request P.O. Box 125 New York, NY Fax: (646) RE: Election Request for Exemption from Medicare Secondary Payer Rules To whom it may concern: [Name of the Multiple Employer Group/Trust/Association], a multiple employer group health plan (the MEG ), provides medical, hospital, and pharmacy coverage to a number of employers. The MEG purchases such coverage from Premera Blue Cross effective [date]. The MEG has a number of participating employers, which would qualify as a small employer group 1 under the Medicare Secondary statute. However, the MEG also has at least one participating employer that does not qualify as a small employer group and, therefore, must elect that Medicare pay primary for the working-aged employees and their spouses who are covered through a small employer group. As provided under 42 USC 1395y(b)(1)(A)(iii), this letter shall serve as the MEG s election that Medicare pay primary for any working-aged employees and their spouses who are employed by the small employer groups providing letters attached as Exhibit A. Pursuant to CMS policy, we are enclosing in support of this election request (1) letters executed by the relevant employers specifying the current number of employees and attesting that they meet the definition of a small employer under the MSP laws, providing their addresses and tax identification numbers, and providing the name, date of birth and social security (or HIC) number for each employee and their spouse for which the request applies; (2) an aggregated list of the affected Medicare beneficiaries that identifies each person s effective date of coverage with the MEG and Premera Blue Cross and the name of the applicable small employer group (see Exhibit A); and the letter to be sent to each Medicare beneficiary explaining that Medicare will pay primary to the MEG. Please send correspondence concerning this election to [Name and address of contact person at MEG]. Sincerely, [Name] [Title] 1 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 Enrollee Notification Letter Sample enrollee notification letter Letter To Be Sent to All Working Aged Medicare Beneficiaries [Date] [Name of Affected Enrollee] [Address of Affected Enrollee] RE: Notice of Medicare as Primary Payer on Health Care Claims Dear [Name of Affected Enrollee]: Medicare requires that [Name of MEG] send you this notice. 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. As you know, [Name of Employer] obtains health insurance coverage through [Name of the MEG], which is a multiple employer group. Also, [Name of Employer] is considered a small employer as defined by law. [Name of MEG] made an election that Medicare would pay primary and [Name of MEG] would pay secondary on your health care claims. If you are married, this same rule applies to your spouse, if your spouse is also a Medicare beneficiary. This letter is for your informational purposes only and you need not take any further action. If you have questions, call [Name of Person], the [Title] for [Name of MEG]. Sincerely, [Name] [Title] 5

6 Sample Small Employer Letter Sample Employer Size Attestation Letter to be included as an exhibit to MSP exception request submitted by multiple employer group health plan to CMS. Place on Employer s Letterhead [Date] [Name of MEG] [Address of MEG] RE: MSP Employer Size Attestation Tax Identification Number/Employer Identification Number: Dear [MEG]: [Name of employer] is an employer group receiving medical, hospital and pharmacy coverage through [Name of MEG]. [Name of MEG] purchases such coverage through Premera Blue Cross. 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 preceeding 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). 6

7 Sample Exhibit 1 List to be included as an exhibit to the small employer letter submitted to the multiple employer group health plan to CMS Exhibit 1: 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 based on their (or their spouse s) current employment status with [insert name of small employer]. Name Date of Birth Social Security or Medicare Health Insurance Claim Number Effective Date of Coverage with MEG

8 Find more information online Sample exception request, enrollee notification and small employer letters available at in the Employers section. 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 ( )