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If an employer, having fewer than 20 full and/or part-time employees, sponsors or contributes to a single-employer GHP, the MSP rules applicable to individuals entitled to Medicare on the basis of age do not apply to such individuals. Nonetheless, if such an employer participates in a multiple employer or multi-employer GHP (multi-employer GHP) and at least one participating employer has at least 20 full and/or part-time employees, these MSP rules apply to all individuals entitled to Medicare on the basis of age, including those associated with the employer having fewer than 20 employees. However, the law provides that a multi-employer GHP may be granted an exception with respect to certain individuals entitled to Medicare on the basis of age and who are covered as a named insured or spouse (covered individual) of an employer with fewer than 20 full and/or part-time employees. In order for an MSP Small Employer Exception (SEE) to exist, the multi-employer GHP must request and the Centers for Medicare & Medicaid Services' (CMS') Coordination of Benefits Contractor (COBC) must approve the requested exception to the Working-Aged MSP rules. An approved exception will apply only with respect to the specifically named and approved beneficiaries associated with a specifically named employer participant in a specifically identified multi-employer plan. This exception applies only to individuals entitled to Medicare on the basis of age. All approvals are prospective. To request Medicare approval of a SEE, the multi-employer GHP must submit a written request, with all required supporting documents, to the CMS' COBC stating that the plan seeks to elect Medicare as the primary payer for identified beneficiaries who are associated with identified employers that participate in the specific multi-employer plan. For the purposes of requesting the SEE, the term multi-employer GHP shall mean any trust, plan, association or any other arrangement made by one or more employers to contribute, sponsor, directly provide health benefits, or facilitate directly or indirectly the acquisition of health insurance by an employer member. (If such facilitation exists, the employer is considered to be a participant in a multi-employer GHP even if it has a separate contract with an insurer.) However, the GHP can, by agreement or otherwise, delegate the responsibility for requesting the SEE to the insurer. To Apply for an Exception The multi or multiple employer plan/authorized insurer should submit all requests for exceptions to the Coordination of Benefits Coordinator. Only those requests that are considered complete will be evaluated. Incomplete requests will be returned for completion and resubmission. In order to be considered complete, the request must be written and addressed to the COBC and contain all of the requirements listed below for each covered individual for whom an exception is being requested: - Statement that the plan elects Medicare as the primary payer for identified beneficiaries who are employees or spouses of identified employers that qualify for such an exception; - The following information for each worker (beneficiary), his or her spouse for whom the plan is requesting Medicare be the primary payer: 1. A letter from the employer that specifies the number of employees that the employer employs and a statement that the employer does not meet the requirements of the 20-or-more employee provision. The full name, date of birth, and Health Insurance Claim Number (HICN) (or Social Security number (SSN), if HICN is not available) for each worker (beneficiary), their spouse or family member, for which the request applies; 2. The employer's name, address, and Tax Identification Number (TIN) or Employer Identification Number (EIN); 3. The name of the insurer, type of coverage and effective date of the coverage for the employer-sponsored insurance. -If the request is being made by an authorized insurer, the insurer must submit a copy of the signed authorizations from the multi or multiple employer plan. Plan administrators/insurers should note the following before applying for a Small Employer Exception: - No exception based upon employer size exists for beneficiaries entitled to Medicare based on permanent kidney failure (End-Stage Renal Disease. - If any participating employer is a multi or multiple employer plan who has at least 100 full and/or part-time employees, the plan is primary for all individuals entitled to Medicare on the basis of disability who have coverage based on their own or family member's current employment status. - The date of the request will serve as the effective date, unless the request is dated more than 7 days prior to the receipt date, in which case, the receipt date will be used. - The effective date for requests that were returned for missing information will be based on the date the completed request is received in the COBC. - When the employer employs a new individual who could be subject to the exception, the plan shall notify the COBC and provide the required information for that individual. - The plan must notify the COBC when the exempt employer meets or exceeds the 20-employee threshold or when there has been a change in the individual's employment or GHP coverage. - The plan is required to notify each worker (beneficiary), his or her spouse for whom the plan is requesting Medicare be the primary payer. Mail or fax completed requests to: Mailed Requests Medicare Coordination of Benefits Attn: Small Employer Exception Request P.O. Box 125 New York, NY 10274-0125 Faxed Requests: Address fax to: Medicare Coordination of Benefits Contractor Attention: Small Employer Exception Request Fax # (646) 458-6761 The COB Contractor will provide the plan administrator/insurer with written confirmation after completion of its review and if applicable, processing, of the request. Approved requests will include a listing of the individual(s) for whom the small employer exception with respect to a specific plan and a specific employer has been approved. It is important that the plan/insurer notify each Medicare beneficiary in writing of the date Medicare will become the primary payer and when the employer GHP will pay secondary to Medicare. If the beneficiary is not enrolled in Medicare Part B and wishes to do so, the plan/insurer should advise the beneficiary to contact his/her local Social Security district office as soon as possible, and supply the affected beneficiary with the information required to apply for Part B benefits.
Page Last Modified: 10/28/2008 8:56:58 AM
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