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pdfMEDICARE - Coordination of Benefits
1- 800-999-1118 or (TTY/TDD): 1-800-318-8782
PLEASE DELIVER THE ENCLOSED REPORT AND INSTRUCTION BOOKLET
IMMEDIATELY TO THE PERSONNEL DEPARTMENT.
INSTRUCTIONS
FOR COMPLETING THE
GROUP HEALTH PLAN REPORT
FOR THE IRS/SSA/CMS DATA MATCH
NOTICE TO EMPLOYERS:
•
You are required by law {42 USC 1395y (b)(5)} to complete this report. The law requires you to
complete this report within 30 days of receipt. Failure to complete this report timely or accurately
could lead to the imposition of a civil monetary penalty.
•
CMS understands that the Data Match Project will prove burdensome to some employers, but we
strongly believe the money saved and recovered through this project far outweighs the burdens.
Completion of the Data Match Questionnaire benefits employers, Medicare beneficiaries covered
by the employer’s group health plans, providers of medical services to Medicare beneficiaries, and
the Medicare program. The employer benefits because medical claims involving Medicare
beneficiaries covered by group health plans are received and processed more quickly, which
reduces administrative expenses and provides better services to covered individuals. Covered
Medicare beneficiaries benefit because their claims are processed correctly in the first instance. In
almost all cases where Medicare is a secondary payer to a group health plan, the beneficiaries’ out
of pocket expenses are lower than they would be otherwise. The Medicare Program benefits
because Medicare makes fewer mistaken primary payments, which reduces trust fund expenses
and the administrative cost of attempting to collect inappropriate payments. In addition, providers,
physicians and other suppliers benefit because the total payments they receive for services
provided to Medicare beneficiaries are greater when Medicare is a secondary payer to a group
health plan than when Medicare is the primary payer.
•
Electronic submission options provided through the IRS/SSA/CMS Data Match Secure Web site
offer convenient and effective methods for completion of the Data Match questionnaire. For
information on Direct Entry, an internet-based option that allows employers, regardless of size, to
complete all questionnaires directly online from multiple locations, turn to page 12 of this booklet.
For information on our Electronic Bulletin Board Service, which is available to employers
required to complete questionnaires on less than 500 workers, turn to page 14.
•
If you are interested in an alternative to the Data Match paper questionnaire, turn to page 16 for
information on a Voluntary Data Sharing Agreement.
•
Please review the instruction booklet for discussion of the reasons why we are requesting this
information and about how you can obtain an extension if you need more than 30 days to
complete this report.
•
Please make a copy of the completed questionnaire for your records and return the completed
original to the address specified below.
ADDRESS:
TELEPHONE:
MEDICARE – Coordination of Benefits
1-800-999-1118
IRS/SSA/CMS Data Match Project
or (TTY/TDD): 1-800-318-8782
P.O. Box 33848 Detroit, MI 48232-5848eb site: www.cms.hhs.gov/COBGeneralinformation
P.O. Box 33848 • Detroit • MI • 48232-5848
(A CMS Contractor)
IRS/SSA/CMS DATA MATCH QUESTIONNAIRE
Quick Reference Guide for Employers
General Instructions: Please enter all dates in MM/DD/CCYY format. Please type or print legibly using black ink
(Please do not use markers). After completing the questionnaire, make a copy for your records and return the
original to the address specified. For further information and assistance in completing the Group Health Plan
Report, please call our toll-free number: 1-800-999-1118 or (TTY/TDD): 1-800-318-8782. Please do not staple
the returned questionnaire.
Questionnaire Part I
Questionnaire Part III
• If you answer "NO" to both Questions 1a and 1b, DO
NOT answer any of the other questions in Part I, II, or III.
Proceed to Part IV and fill in the Certification
information. Then return Part I, Page 1, and Part IV
using the self-addressed label or envelope provided.
For an example, see page 19 of this booklet.
• If you answer "NO" for all of the years identified in
Question 2 and 3, DO NOT answer Questions 4 and 5, nor
Part II and Part III. Proceed to Part IV and fill in the
Certification information. Then return Part I and Part
IV using the self-addressed label or envelope provided.
• For further information on this part of the
questionnaire, please continue to page 5 of this booklet.
• If you answer "NO" to Question 1, DO NOT
CONTINUE. Proceed to the next individual's report.
• If you answer "YES" to Question 1 or 2, proceed to the
questions that follow.
• If you answer "NO" to Question 2, provide the date the
individual stopped working for your organization. If this
date is prior to the date specified on the report, STOP, DO
NOT CONTINUE. Proceed to the next individual's report.
For an example, see page 24 of this booklet.
• If you answer "NO" to Question 3, STOP, DO NOT
CONTINUE. Proceed to the next individual's report.
• For Question 4a, enter the LATER of the following:
The date specified on the report;
OR,
The date that the individual started working for
your organization.
• For Question 4b, enter the calendar date you provided
in your answer to Question 2. If no date was given in Question 2, enter the date you prepared this report.
• In Question 5, report the group health plan coverage
selected by the individual during the period between your
answers to Questions 4a and 4b. Provide the beginning
and ending dates for each period of coverage. Account for
any period that the individual was not covered under a
GHP by indicating a coverage elected of "NONE". For an
example, see pages 22 through 23 of this booklet.
• NOTE: If the individual identified is or was covered by
a collectively bargained health and welfare fund, go to page
11 of this booklet for instructions on how to complete the
answer to this question. The GHP Report number should
match one of the GHP Report numbers from Part II of the
report.
• For further information on this part of the questionnaire, please refer to pages 8 through 11, for an example,
see pages 22 through 23 of this booklet.
Questionnaire Part II
• NOTE:
Complete and return this part of the
questionnaire only if you answered "YES" to any year in Part
I, Questions 2, 3, 4, or 5, and you have offered a Group
Health Plan (GHP) to any worker identified in Part III. Fill
out information only on those GHPs that pertain to these
workers.
• In Part II Page 1, we have provided a page with three
pre-assigned GHP Report Numbers (0001-0003) and a
second page with blank GHP blocks to record additional
GHPs, if needed. Each GHP identified must be given a
single and unique report number. Please use the first
page for the first three GHPs and the second page for any
additional plans.
• NOTE: Once you have assigned a Report Number to a
particular health plan that number CANNOT be used
again in this section of the report. These numbers should
not be duplicated, since they are used to identify group
health plans for workers identified in Part III. For an
example, see page 21 of this booklet.
• Please provide the complete name, address (street
name/number, city, state, and ZIP Code), Group ID
Number or Code, Insurer/Third Party Administrator(TPA)
Tax identification number (TIN), Rx BIN, Rx PCN, Rx
Group (if applicable), and only one GHP type, for each
GHP listed.
• For further information on this part of the
questionnaire, please continue to page 6, 7, and 8 of this
booklet.
Questionnaire Part IV
• It is essential that this section of the report is
completed. Please indicate the name and title of the
individual who is certifying this document.
• For further information on this part of the
questionnaire, please refer to page 11, for an example, see
page 22.
Table of Contents
QUICK REFERENCE GUIDE FOR EMPLOYERS .............................................................................. inside front cover
BACKGROUND INFORMATION
Employer Group Health Plans and the Medicare Secondary Payer Program ..................................... ii
Who does MSP affect? (ii); Employer Responsibilities under MSP (iii); Making MSP Work (iv)
GENERAL INFORMATION
How to Complete the Data Match Questionnaires ............................................................................. 3
Instructions for Completing Part I ...................................................................................................... 5
Instructions for Completing Part II ..................................................................................................... 6
Instructions for Completing Part III .................................................................................................... 8
Instructions for Completing Part IV .................................................................................................. 11
Information on Direct Entry on the IRS/SSA/CMS Data Match Secure Web Site .............................. 12
Information on the Bulletin Board Service ....................................................................................... 14
Information on Voluntary Data Sharing Agreements........................................................................ 16
EXAMPLES OF COMPLETED EMPLOYER REPORTS
Pitstop Inc........................................................................................................................................ 19
Jack’s Cafe........................................................................................................................................ 20
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-0565.
The projected burden for completing this report is dependent upon several factors. The number of individuals
for whom you are requested to supply information has the largest impact on the paperwork burden. Other factors
which may increase the burden are the accessibility and format of personnel and health plan records, the number of
group health plans offered by the organization, and the frequency of changes between plans or in coverage
elections. The projected average burden for completing this report (including time for reviewing instructions,
searching existing data sources, gathering and maintaining data needed, and completing and reviewing the
collection of information) is as follows:
Number of Employees for Whom
Estimated Average
Information is Requested
Burden Hours
1
2
2 10
4
11 25
6
26 50
12
51 100
24
101 200
48
201 - 1,000
100
> 1,000
200
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing the burden, to:
Centers for Medicare & Medicaid Services
Attn: PRA Reports Clearance Officer
7500 Security Boulevard
Baltimore, MD 21244-1850
This information is being collected under contract (CMS 500-00-0001) with the United States Department of Health
and Human Services for use by the Medicare program.
MSP Data Match Project, Instructions for Employers
Page i
Background Information:
Employer Group Health Plans and the Medicare Secondary Payer Program
Some people who have Medicare also
have group health coverage.
Usually,
Medicare is their primary payer, which
means that Medicare pays first on their
health care claims. Sometimes, the other
plan must pay first. In that case, Medicare is
the secondary payer.
Until 1980, the Medicare program was
the primary payer in all cases except those
involving workers’ compensation (including
black lung benefits) or veterans benefits.
Since 1980, new laws have made Medicare
the secondary payer for several additional
categories of people.
The additional
categories of people for whom Medicare is
the secondary payer are described below.
Medicare Secondary Payer
Medicare secondary payer (MSP) is the
term used by Medicare when Medicare is not
responsible for paying first. (The private
insurance industry generally talks about
“coordination of benefits” when assigning
responsibility for first and second payment.)
The terms “Medicare supplement” and
“Medicare secondary payer” are sometimes
confused. A Medicare supplement (Medigap)
policy is a private health insurance policy
designed specifically to fill in some of the
“gaps” in Medicare’s coverage when
Medicare is the primary payer. Medicare
supplement policies typically pay for
expenses that Medicare does not pay because
of deductible or coinsurance amounts or
other limits under the Medicare program. An
employer cannot offer, subsidize, or be
involved in the arrangement of a Medicare
supplement policy where the law makes
Medicare the secondary payer. (See page iv
on the IMPORTANT WARNING FOR
EMPLOYERS).
Federal law takes precedence over
conflicting State law and private contracts.
Thus, for the categories of people described
below, Medicare is secondary payer
regardless of state law or plan provisions.
These Federal requirements are found in
Section 1862(b) of the Social Security Act (42
U.S.C. Section 1395y(b)).
Applicable
regulations are found at 42 C.F.R. Part 411
(1990). You should verify that your group
health plan is in conformity with these
Page ii
Federal documents. The official Federal
requirements are contained in the relevant
laws and regulations.
Who does MSP affect?
Medicare is now secondary payer to
some group health plans (GHPs) or large
group health plans (LGHPs) for services
provided to the following groups of Medicare
beneficiaries:
• The “working aged,”
• People with permanent kidney failure,
and
• Certain disabled people.
As used in this booklet, a GHP/LGHP is:
• a plan that provides health care, either
directly or indirectly through insurance
or otherwise,
• provided to employees, former
employees, or the families of employees
or former employees, and contributed
to or sponsored by an employer.
A GHP/LGHP includes those plans
where employees pay all the costs.
The term plan includes insurance plans,
prepaid arrangements, and self-insured
plans. A plan can be any arrangement
between one or more parties for the
provision of health care. The arrangements
may be oral or written.
Working Aged
The “working aged” are employed people
age 65 or over and people age 65 or over with
employed spouses of any age who have GHP
coverage because of their or their spouse’s
current employment status. In general, an
individual has current employment status if
the individual is an employee, the employer,
or is associated with an employer in a
business relationship.
Medicare is secondary payer to GHPs for
the “working aged” where either:
• a single employer of 20 or more employees is the sponsor of the GHP or a
contributor to the GHP,
or
• two or more employers are sponsors or
contributors, and at least one of them
has 20 or more employees.
The “20 or more employees” threshold is
met whenever an employer has 20 or more
full and/or part time employees for 20 or
more calendar weeks in the current calendar
year or the preceding calendar year. This
may be determined by the number of
employees on the payroll on any given
workweek.
To illustrate; The ABC
Corporation has 50 employees on its payroll
every week. This consists of a staff of 10 full
time employees who come in on Monday,
Tuesday, and Wednesday and 40 part-time
employees who only come in on Thursday
and Friday. Due to the number of employees
physically on the job for that calendar
workweek, the ABC Corporation meets the 20
or more threshold.
When determining the “20 or more
threshold,” employers (i.e., individual or
wholly owned entities) with more than one
company must follow the IRS aggregation
rules. In cases where an employer wholly
owns more than one company, all
employees of all the organizations in
question are counted toward the 20 or more
threshold. For example, the XYZ company
has six subsidiaries.
Each individual
subsidiary has a total of 5 employees that
worked 20 or more weeks for the calendar
year. The 20 or more threshold is met with
company XYZ because their number of
aggregated employees total thirty. The
relevant IRS codes can be found in 26 U.S.C.
sections 52(a), 52(b), 414 (n) (2).
Medicare is the secondary payer regardless of how many employees are eligible to
enroll or actually enroll in the plan.
For GHPs with more than one
sponsoring or contributing employer, there
are three possibilities:
• Where all of the employers have less
than 20 employees, Medicare is primary
payer for all working aged people
enrolled in the plan because the plan is
not subject to the MSP provisions.
• Where all of the sponsoring or contributing employers have 20 or more employees, Medicare is secondary payer for all
working aged people enrolled in the
plan.
MSP Data Match Project, Instructions for Employers
• Where some of the sponsoring or contributing employers have 20 or more
employees and some have less than 20,
Medicare is secondary payer for all working aged people enrolled in the plan.
There is one exception: a GHP may
request to exempt those working aged
people enrolled through an employer
with fewer than 20 employees. If CMS
approves the request, Medicare would
become primary payer for specifically
identified working aged people enrolled
through an employer with fewer than 20
employees. The GHP must be able to
document its decision to exempt such
individual. See page 3 of the instruction
booklet, on how you can determine if
this exclusion applies to your
organization.
People with Permanent Kidney Failure
Medicare is secondary payer to GHPs during
a 30-month coordination period for
beneficiaries who have permanent kidney
failure (End Stage Renal Disease), and who
have coverage under a GHP on any basis
(current employment status is not required
as the basis for coverage).
Disabled People
Medicare is the secondary payer for
people under age 65 who have Medicare
because of disability and who are covered
under a LGHP based on the individual’s (or a
family member’s) current employment
status. In general, an individual has current
employment status if the individual is an
employee, the employer, or is associated with
an employer in a business relationship.
A LGHP provides health benefits to
employees, former employees, the employer,
business associates of the employer, or their
families, that covers employees of at least one
employer with 100 or more employees.
•
•
To assure that their plans do not discriminate against employees and employee’s spouses age 65 or over, people
who suffer from permanent kidney
failure, and disabled Medicare beneficiaries for whom Medicare is secondary
payer; and,
To timely and accurately complete data
match reports on identified employees.
Working Aged
If you are an employer with 20 or more
employees, your GHP must not discriminate
against employees age 65 or over, or employees’ spouses age 65 or over, whether or
not they have Medicare. The benefits offered
to these people under your plan must not
differ in any way from the benefits offered to
people who do not have Medicare. Your GHP
must be primary payer for those benefits in
MSP situations, and must not take into account working aged people’s entitlement to
Medicare.
•
•
•
•
•
Employer Responsibilities
under MSP
Employers have a number of important
responsibilities under the MSP law:
• To assure that their plans identify those
individuals to whom the MSP requirements apply;
• To assure that their plans provide for
proper primary payments when the law
makes Medicare the secondary payer;
MSP Data Match Project, Instructions for Employers
GHPs must not, for example:
fail to make primary payment, or make
a smaller payment, on behalf of
someone for whom Medicare is
secondary payer,
reduce or terminate coverage of
employees and employees’ spouses age
65 or over, either (1) because they have
become entitled to Medicare, or (2) because they have attained age 65.
refuse to allow employees and
employees’ spouses age 65 or over to
enroll, or to re-enroll, on the same
basis as younger employees and
spouses,
impose limitations on benefits,
exclusions of benefits, or reductions in
benefits on those age 65 or over that are
not applicable to younger people who
are enrolled in the plan, or
impose higher premiums, higher
deductibles or coinsurance, longer
waiting periods, lower annual or
lifetime benefits, or more restrictive
pre-existing illness conditions for those
age 65 or over than are applicable to
those under age 65 who are enrolled in
the plan.
You must inform employees and
employees’ spouses who are entitled to
Medicare that they may reject coverage
under the plan and choose Medicare as
their primary payer. If they reject
coverage under the employer plan, you
may not offer them, facilitate or
subsidize a plan intended only to
supplement
Medicare’s
benefits.
Employer plans may, however, offer
them coverage for items and services
for which Medicare provides no benefits
(for example, eyeglasses).
Beneficiaries who reject the employer
plan may purchase Medicare supplemental
(Medigap) coverage from some source other
than the employer. The employer may not
subsidize, purchase, or be involved in the
arrangement of an individual supplement
policy for the employee or family member.
People with Permanent Kidney Failure
For people who have Medicare entitlement or eligibility because of permanent
kidney failure, during the first 30 months of
that eligibility or entitlement, the GHP must
be the primary payer. They may not take into
account their eligibility or entitlement to
Medicare based on permanent kidney failure.
The GHP must not, for example, fail to
make primary payment or make a smaller
payment on behalf of someone for whom
Medicare is secondary payer.
In addition, the GHP must not discriminate against them because they have permanent kidney failure. The benefits provided
must not differ in any way from the benefits
provided to persons who do not have permanent kidney failure.
For all people with permanent kidney
failure, with or without Medicare, both
during and after the 30-month period, the
plan may not:
• refuse to allow an individual with permanent kidney failure to enroll, or to reenroll, in the plan, on the same basis as
persons who do not have permanent
kidney failure,
• fail to cover routine maintenance dialysis
services or kidney transplants at the
same level as other services covered by
the plan when the plan covers other
dialysis service or other organ
transplants,
• impose limits on benefits, reduce benefits, or impose exclusions on enrollees
who have permanent kidney failure that
are not applicable to enrollees who do
not have permanent kidney failure, or
Page iii
• impose higher premiums, higher deductibles or co-insurance, longer waiting
periods, lower annual or lifetime
benefits, or more restrictive pre-existing
illness conditions than are applicable to
those who do not have permanent
kidney failure.
Disabled People
A LGHP must not discriminate against
disabled Medicare beneficiaries for whom
Medicare is secondary payer. This means
that it must not treat these people differently
from other enrollees because they are disabled and have Medicare.
For example, with respect to these disabled
Medicare individuals, a LGHP must not:
• fail to make primary payment, or make
a smaller payment on behalf of
someone for whom Medicare is
secondary payer,
• terminate coverage on the basis of entitlement to Medicare,
• provide for different benefits, or a different level of benefits, on the basis of
entitlement to Medicare, or
• charge a higher premium than it
charges to other enrollees in the plan.
Employers must offer disabled Medicare
beneficiaries the opportunity to reject the
LGHP’s coverage. In that case, Medicare
becomes their primary payer, and the
employer must not offer them, subsidize or
be involved in the arrangement of
supplemental (Medigap) coverage, except for
items and services for which Medicare does
not provide coverage (for example,
eyeglasses).
However, as with the working aged,
beneficiaries who reject the LGHP may
purchase Medicare supplemental coverage,
Medigap, from a source other than the
employer, so long as the employer does not
purchase, subsidize, or arrange for the
coverage.
Making MSP Work
The health insuring organizations
under contract to pay Medicare claims
(Medicare carriers and intermediaries) are
responsible to deny claims for primary
benefits when Medicare is secondary payer.
Page iv
These contractors are also responsible for
informing providers, employers, insurers and
beneficiaries about MSP and how it works.
Staff members from Medicare contractors
give talks on MSP to hospital groups,
insurance associations, beneficiary advocacy
organizations and others. A representative of
a Medicare contractor in your area would be
happy to talk with you about MSP or any
other Medicare issue you would like to
discuss.
In making claims processing decisions,
the Medicare contractors utilized information
on the claim form and in the Medicare
systems of records in order to avoid making
mistaken primary payments.
These
payments are made by Medicare where a
GHP or LGHP should properly be the
secondary payer not the primary payer. In
such cases, Medicare will not pay the claim
as a primary payer and will return it to the
claimant with instructions to bill the proper
party.
Sometimes, after a Medicare claim is
paid, a Medicare contractor gets new
information that indicates Medicare made a
primary payment by mistake. Based on this
new information, the contractor seeks to
recover the mistaken Medicare payment.
Contractors will send initial demand
letters for repayment to any or all the parties
obligated to repay Medicare. These parties
include the plan, employer, other plan
sponsor, insurer, and third party
administrator. The parties will be advised
that it or its claims processor must take
specified actions to resolve the repayment
request.
If the parties do not directly (or arrange
with its group health plan or claims
processor to) refund the mistaken payment
or provide the documented defense to the
contractor as requested in the demand letter,
the contractor refers the case to CMS.
CMS will review the case. CMS may refer
the case to the Department of Justice for legal
action if it determines that a properly
documented defense or the required
payment has not been provided. The law
authorizes the Federal government to collect
double damages from any party that is
responsible for resolving the matter but
which fails to do so.
CMS may also refer the case to a debt
collection center or the Treasury Department
for collection pursuit to the provision of the
Debt Collection Improvement Act (DCIA).
CMS may refer any or, all the parties that are
responsible for payment for collection
purposes. Under the DCIA, the government
may take direct action to collect debt from
any responsible parties or may also offset
varies federal payments that may be due to
any or all the parties against the outstanding
debt.
CMS may also report employers that
sponsor or contribute to GHPs that fail to
follow MSP rules – these are called
“nonconforming group health plans” – to
the Internal Revenue Service (IRS). The IRS
is required to impose a tax on the employers
or employee organizations that contribute to
these nonconforming plans. The tax is equal
to 25 percent of all contributions the
employer or employee organization made to
all group health plans during the year. This
tax provision is found in Section 5000 of the
Internal Revenue Code (26 U.S.C. 5000).
IMPORTANT
WARNING FOR EMPLOYERS: CMS wishes to
make sure that employers understand the
legal consequences of purchasing directly or
indirectly an individual Medicare supplemental
(Medigap) policy for an employee or spouse of
an employee. This arrangement constitutes a
GHP under Medicare law and the Internal
Revenue Code. Employers must understand,
that even if they do not contribute to the
premium, but merely collect it and forward it
to the appropriate individual’s insurance
company, the arrangement must be a primary
payer to Medicare. In addition, the plan,
because it takes into account the Medicare
entitlement of the beneficiary, is also a nonconforming GHP which would subject the
employer to possible excise taxes. If you have
provided such coverage to Medicare
beneficiaries, we urge you to write to CMS,
Office of Financial Management, Division of
Financial Integrity to explain the situation and
to take appropriate corrective actions.
MSP Data Match Project, Instructions for Employers
Important Notice on Potential Health Insurance Costs Reduction
(OBRA 93 Transition Process for Disabled Medicare Beneficiaries)
The Centers for Medicare & Medicaid Services is issuing this important alert to all employers. Specifically, this notice advises you that Medicare can
become primary payer for certain disabled Medicare beneficiaries for whom your group health plan may currently be making primary payment.
This means that your health insurance costs could be reduced.
HOW DOES THIS WORK?
Effective August 10, 1993, § 13562 of the Omnibus Budget Reconciliation Act of 1993 (“OBRA 93”), made Medicare the secondary payer for people
under age 65 who have Medicare because of disability and who are covered under a large group health plan (LGHP) based on the individual’s (or a
family member’s) current employment status. An individual has “current employment status” with an employer if he/she is an employee, is the
employer (including self-employed persons), or is associated with the employer in a business relationship.
Prior to August 10, 1993, Medicare was also the secondary payer for a disabled individual who was under the age of 65, and who was also enrolled
in a LGHP, if Medicare determined they were actively working for the employer despite their disability (such as disabled Medicare beneficiaries
engaged in a trial work period) or were not actively working but whom the employer treated as an employee. Medicare decided whether or not a
person was an “active individual” as defined in the law. For this category of people Medicare is now primary
Because Medicare did not have information to distinguish whether disabled Medicare beneficiaries had that coverage based on current
employment status, on July 14, 1994, CMS published a notice in the Federal Register, at 59 FR 35935, which explained procedures employers
could use to transition their affected beneficiaries to the new rules.
WHY IS THIS AN ISSUE TODAY?
OBRA 93 did not authorize Medicare to compel employers to transition to the new rules. As a result, even after Congress changed the law,
Medicare found that some employers chose to continue providing primary health coverage to some non-working disabled Medicare beneficiaries
when not required to do so. However, recent events have indicated a need to provide you with more information.
We have become aware of several outside groups that have been soliciting employers by offering to manage the entire transition process for the
employers. For a fee, these outside groups are offering to submit information to Medicare, on behalf of employers, so as to make Medicare the
primary payer for those disabled Medicare beneficiaries that do not have coverage based on current employment status. We have also been
receiving inquiries from employers, providers, and Medicare beneficiaries about retroactively applying the OBRA 93 change.
You may be unknowingly placing an unnecessary financial burden on both your company and these disabled Medicare beneficiaries if you are not
fully informed of the following:
WHAT YOU SHOULD KNOW:
•
Several of these outside groups that are soliciting employers are implying that they have a special relationship with Medicare or, in some
instances, are implying that they are authorized to act on behalf of Medicare. These outside groups do not have any relationship to Medicare.
•
Employers need not contract with any entity to transition the affected disabled Medicare beneficiaries to the OBRA 93 rules. An employer can
make these changes directly with Medicare at no cost. The transition requirements are not complicated. Please call our Coordination of
Benefits contractor at 1-800-999-1118 or (TTY/TDD) 1-800-318-8782 and they will give you more information.
•
We understand that some employers are being encouraged to seek to make Medicare the primary payer retroactively to as early as August 10,
1993, and that employers are incorrectly being told that Medicare will make primary payments as far back as 1993. You should know that
retroactive implementation may conflict with both your interests and affected disabled beneficiaries’ interests. Also, because Medicare may
pay only providers and suppliers of medical services, or in some cases, beneficiaries, and because Medicare has time limits for filing claims,
you will not likely be able to recover payments as far back as 1993. To minimize your time and costs, and to protect the interest of the
MSP Data Match Project, Instructions for Employers
Page 1
disabled Medicare beneficiaries, you may want to consider prospective changes rather than retroactive changes.
•
You may be asked to sign a statement authorizing someone to act as an agent on your behalf. You should understand the legal consequences
of such an appointment, so as not to create unintended results.
•
If you decide to have someone act as your agent, you should be aware that the same agent may represent or seek to represent the disabled
Medicare beneficiaries. This could pose a conflict of interest. We have been contacted by some beneficiaries who believe they were asked to
sign open-ended appointments of representation or who believe that their best interests were not properly represented.
IF YOU DECIDE TO TRANSITION RETROACTIVELY
•
Beneficiaries could be asked to pay Medicare Part B premiums back to the date they enrolled. This could amount to several thousand dollars
for some beneficiaries. Conversely, your company may also be liable to your disabled employees for any employee contributions to your
insurance plan if you are retroactively changing coverage. These changes could be administratively burdensome for you or your plan.
•
Because Medicare primary payments are often less than private insurer primary payments, beneficiary out-of-pocket expenses could go up.
Retroactive claims filing could create substantial costs for affected beneficiaries.
•
The amount of primary payments that you may be able to recoup will be significantly limited by the following four factors. First, Medicare
claims may only be submitted by providers and suppliers of the service, or in some instances, by the beneficiaries. Second, Medicare will not
honor new claims if they are not submitted timely. Third, the time frame to reopen claims previously processed for secondary payment
would, in most of these cases, be limited to one year from the date the Medicare secondary payment was determined. Fourth, physicians and
suppliers that have already received primary payment from a private insurer may be unwilling or unable to refund that payment and bill
Medicare.
•
There may be additional costs to your company or plan, such as additional accounting and bookkeeping costs, related to making the change
retroactive, as well as costs related to properly informing affected plan participants about their options for transitioning.
For further information, please call our Coordination of Benefits Contractor at 1-800-999-1118 or (TTY/TDD) 1-800-318-8782.
Page 2
MSP Data Match Project, Instructions for Employers
General Information:
How to Complete the Data Match Questionnaires
NOTE: If you participate in a collectivelyIn late 1989, a law was enacted (Section 6202
bargained health and welfare fund
of the Omnibus Budget Reconciliation Act of
or a multiple employer plan, it may
1989) to provide CMS with better information
be necessary for you to contact the
about Medicare beneficiaries’ group health
plan administrator to complete
plan coverage.
some of the sections of this report.
The law requires the IRS, the Social
Please do so early enough to assure
Security Administration (SSA), and CMS to
that you will comply with the time
share information that each agency has about
frame stipulated in the law for
whether Medicare beneficiaries or their
completion of these questionnaires.
spouses are working. The process for sharing
For example, you may need to contact the
this information is called the IRS/SSA/CMS
plan
administrator to find out if there is one
Data Match.
employer in the plan that has or has had 20
The purpose of the Data Match is to
or more full-time and/or part-time employees
identify situations where another payer may
during the years listed on your data match
be primary to Medicare.
report. Also, you would need to find out if
The Data Match identifies employers of
there is one employer who has/had 100 or
beneficiaries for whom employer coverage, if
more full-time and/or part-time employees in
available, is likely to be primary to Medicare.
any year listed on your data match report. DO
The law requires that CMS contact these
NOT ask the plan administrator if there is/was
employers to confirm coverage information.
an employer with 20 or 100 individuals
Your compliance with this law will identify
eligible for coverage or covered under the
potential situations in which Medicare is not
plan. The requirements of the law are based
the primary payer.
on the number of employees, not the number
of individuals eligible for coverage or covered
This publication is intended to assist and
under a plan.
guide you through the timely completion of
the Data Match Project (DMP) QuestionThis report may look different from other
naires, Parts I, II, III and IV. You should read
reports you are required to submit to the
through the entire instruction booklet and
government. A major difference is that
review your data match report before you
certain worker information has already been
begin to complete the report.
completed for you. This identified worker
information is the result of the IRS/SSA/CMS
Depending on your organization’s anData Match process. You should note that
swers to the questions in Part I, it may not be
these individuals were identified because
necessary to complete Parts II and III. It is
either the worker or the worker’s spouse
extremely important that all instructions are
is/was a Medicare beneficiary.
carefully and closely read and that all answers
to the questionnaires provided by you are
Any employer that has multiple Employer
accurate. You should send the original
Identification Numbers (EINs) and would like
questionnaires back to the designated address
all data sent to one central location for
and keep a copy for yourself.
response may arrange for this. The request
must
be made in writing, to our post office box
Applicable Federal MSP requirements are
address
noted below. Please inform all entities
found in Section 1862(b) of the Social Securin
your
organization that you are making this
ity Act (42 U.S.C. Section 1395y(b)) and at 42
request.
C.F.R. Part 411 (1990). You should verify that
your group health plan is in conformity with
The law requires that you complete the
these Federal requirements. This instruction
enclosed report within 30 days. Employers
booklet clarifies the procedures for
who willfully or repeatedly fail to report, or who
completion of these questionnaires. However,
provide inaccurate or incomplete information,
it is not a legal document. The official Federal
may be assessed a civil monetary penalty of up
requirements are contained in the relevant
to $1,000 for each individual for whom an
laws, regulations, and rulings.
inquiry concerning health care coverage was
made.
MSP Data Match Project, Instructions for Employers
However, if you have thoroughly reviewed
this instruction booklet and conclude that the
information gathering and reporting will
require more than the allotted 30 days, you
may request an extension of an extra thirty
days by calling our toll-free telephone number:
1-800-999-1118 or (TTY/TDD): 1-800-3188782.
Any request for an extension beyond these 60
days for filing will require you to detail the
reasons in a letter written to:
Medicare – Coordination of Benefits
IRS/SSA/CMS Data Match Project
P. O. Box 33848
Detroit, MI 48232-5848
In general, extensions beyond the 60-day
period (the original 30 days and one 30-day
extension) will not be granted to any employer
who is required to report on less than 150
workers (Part III of the data match report).
Extensions beyond the 60-day period for those
employers with more than 150 workers will be
considered on a case-by-case basis.
If you have more than 150 workers identified
in Part III of your data match report and do
not believe you can complete the report in 60
days, you should immediately request an
extension over the phone and request an
additional extension in writing. Your written
request should contain the following:
• The name of your organization;
• The employer identification number (EIN)
of your organization;
• Any associated EINs if you are a parent
organization and wish to have all EINs
aggregated; and,
• An explanation of the problem or difficulty
that precludes completion of the
questionnaire in 30 or 60 days and the
actions you are taking to resolve the
problem or difficulty.
• A proposed completion date.
NOTE: The assessment of a civil monetary
penalty will not relieve the employer
of the requirement to provide this
information.
Page 3
Definitions of Terms Used in these Instructions
The definitions listed below will help you
to understand the terminology used in
these instructions:
Employer: Individuals and organizations
engaged in a trade or business, plus
entities exempt from income tax such as
religious, charitable, and educational
institutions, the governments of the
United States, the individual States,
Puerto Rico, the Virgin Islands, Guam,
American Samoa, the Northern Mariana
Islands, and the District of Columbia,
and the agencies, instrumentalities, and
political subdivisions of these governments.
Group Health Plan (GHP): Any plan of, or
contributed to by, an employer (including a self-insured plan) to provide
health care (directly or otherwise) to the
employer’s employees, former employees, or the families of such employees or
former employees. This includes plans
where the employee pays all costs, i.e.,
through payroll deductions.
NOTE: For the purposes of completing this
report, the term “GHP” includes LGHPs
(Large Group Health Plans).
-see page ii for definition.
Third Party Administrator: A TPA is an
entity
that
performs
certain
administrative functions of the GHP but
does not provide insurance coverage.
An Insurer:
of a GHP is an entity that, in exchange
for payment of a premium, agrees to pay
for GHP covered services received by
eligible individuals.
Worker Only Coverage: For the purposes of
completing this report, “worker only”
coverage is coverage that covers the
worker, but not the worker’s spouse.
This option should be used when
coverage exists for the worker and their
dependents other than the worker’s
spouse. .
Family Coverage: For the purposes of
completing this report, “family”
coverage is coverage that covers both the
worker and the worker’s spouse. This
does not include coverage that covers
the worker and the worker’s dependent
child.
GHP Identification Number (or Code):
Page 4
This identifies the policy or contract
number(s) under which workers are
covered for health insurance. Not all
plans issue identification numbers.
Earliest Potential MSP (EPM) date: This
is the pre-printed date referenced for
each worker on the Part III form(s). It
represents the date calculated as the
earliest potential Medicare Secondary
Payer (MSP) date for either the worker,
or the worker’s spouse. This date will
vary for each worker.
NOTE: See page ii for definition of MSP.
Employer Identification Number (EIN):
This is the number employers use when
reporting employees earnings to the
Internal Revenue Service (IRS). It is often
referred to as the employer’s Federal Tax
Identification Number.
Employee: For purposes of the MSP
provisions, an employee is an individual
who works for an employer, whether on a
full or part-time basis, and receives
remuneration for their work. The
employees (workers) identified in Part III
of the data match report are individuals
for whom a W-2 form was filed under
your employer identification number.
Collectively-Bargained
Health
and
Welfare Fund: Also referred to as a
multi-employer health plan organized
under a collective bargaining agreement.
An “union” plan is an example of a multiemployer plan.
Civil Monetary Penalty (CMP): An amount
of money that may be levied or assessed
by the Federal government against an
organization, corporation, company or
individual for failure to comply with
existing Federal statutes or laws.
Personal Identification Number (PIN):
This number appears on Part I, Page 1 of
the Data Match Questionnaire. It is a 4
digit number that is used by employers to
access the IRS/SSA/CMS Data Match
Secure Web site and the Data Match
Bulletin Board Service (BBS). For further
information on the BBS, please see page
14 of this booklet.
Tax Identification Number (TIN)
The vast majority of GHPs are separate
legal entities with unique TINS or the
TIN of the employer/sponsor with a
unique suffix. Provide the unique TIN
of the GHP you have identified. If you
do not know the TIN, you may need to
consult your financial officer.
If you need further clarification regarding
terminology or other information, please call
our toll-free number 1-800-999-1118 or
(TTY/TDD): 1-800-318-8782.
Multi-Employer Plan: These group plans
involve arrangements with “collectively
bargained health and welfare funds” (see
above).
Multiple Employer Plan: A plan sponsored
by two or more employers. These are
generally plans that are offered through
membership in an association or trade
group. An example would be a local
small business association who offers
those employers who are members of the
association the opportunity to purchase
Group Health Plan coverage for their
employees at a better rate because the
employers have joined together to form a
multiple employer plan.
Part-Time Employment: Part-time employment for a particular employer is less
than whatever hours the employer considers to be full-time employment.
MSP Data Match Project, Instructions for Employers
Instructions for Completing Part I
Question 1a: Did you offer a
health plan to any employee at any time
since
(pre-printed date) ? (full or
part-time)
Please answer either YES or NO, if any type
of health plan was offered to full time and/or
part time employees.
Question 1b: Did your organization
make contributions on behalf of any
employee who was covered under a
collectively bargained Health and
Welfare Fund (e.g. a union plan) since
(pre-printed date) ?
Please answer either Yes or No if your
organization makes contributions on behalf
of any employee who was or is covered
under a collectively bargained Health and
Welfare Fund (e.g. a union plan).
NOTE: If you answered NO to both
questions 1a and 1b, you do not
have to answer any of the other
questions in Part I. Proceed to
Part IV and fill in the Certification
information. Return Parts I and IV
using the self-addressed mailer or
label provided.
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)?
Please answer YES or NO as to whether
there were 20 or more full and/or part time
employees for 20 or more calendar weeks
for each of the listed years.
SPECIAL NOTE: If you are involved in a
Multi-employer or Multiple Employer Group
Health Plan, it may be necessary for you to
contact your plan administrator in order to
answer these questions. Employers must
follow the IRS aggregation rules to
determine whether the “20 or more
threshold” is met, please refer to page ii of
this booklet.
NOTE: If there was a year listed in this
report for either Question 2, 3, 4 or
5 for which you were not in
business, please indicate NO for
that year.
Question 3: In the following years
did your organization participate in a
multi or multiple employer group
health plan in which there was at least
one employer who had 20 or more
employees for 20 or more calendar
weeks (this include full time, parttime,
intermittent
and/or
s e a s o n a l employees)?
For each of the years listed, check YES or
NO as to whether your organization
participated in a multi- or multipleemployer Group Health Plan in which there
was at least one employer who had 20 or
more full and/or part time employees for 20
or more calendar weeks.
SPECIAL NOTE: For a definition of a
Multi/Multiple Employer Plan, please refer
to page 4 of this booklet or call our tollfree number 1-800-999-1118 or
(TTY/TDD): 1-800-318-8782.
NOTE: If you answered NO for all of the
years identified in Questions 2
AND 3, you do not have to answer
Questions 4 and 5. Fill in the
Certification on Part IV and return
Parts I and IV using the selfaddressed mailer or label
provided.
NOTE: If you answered YES to ANY of
Questions 2, 3, 4, or 5, you will
need to complete the remaining
sections of this report.
Some employers may be exempt from
the MSP “working aged” rules if they are in
a multiple or multi-employer plan. This exclusion may be applicable to your organization if you answered NO for each year listed
in Part I, Question 2. You may wish to write
to the multiple employer plan administrator
and ask if the Multiple Employer Plan has
requested and CMS has approved an
exception to the Working Aged MSP rules
that apply to your GHP. You should ask for a
copy of the GHP’s request and CMS’s
approval to be certain that you complete the
questionnaire correctly.
However, no
exclusions can be made for End Stage Renal
D i s e a s e b e n e f i c i a r i e s o r di s a b l e d
beneficiaries. Please call the toll-free line
(1-800-999-1118) and we will help you
determine if your organization is eligible for
the “working aged” exclusion.
Question 4: In the following years,
did you have 100 or more employees
during 50% of your business days full
or part-time)?
Please answer YES or NO as to whether
there were 100 or more full and/or part
time employees during 50 percent of the
business days during each of the listed
years.
Question 5: In the following years,
did your organization participate in a
multi or multiple employer group
health plan 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)?
For each of the years listed, check YES or
NO as to whether your organization
participated in a multi- or multipleemployer Group Health Plan in which there
was at least one employer who has had 100
or more full and/or part time employees
during 50 percent of the business days in
the year listed.
MSP Data Match Project, Instructions for Employers
Page 5
Instructions for Completing Part II
If you answered YES for any year listed in
Part I, Questions 2 through 5, you are required
to complete Part II. You need to fill out information only on those Group Health Plans
(GHPs) that involve workers identified in Part
III of this questionnaire.
You do not need to complete information
on any GHP offered by your organization if
there are no workers identified in Part III that
have or have had coverage under that GHP.
You must include all GHPs under which a
worker identified in Part III has or has had
coverage during the time period identified for
that worker.
The health benefit choices that you may
offer to employees may consist of many
different health plans and choices under each
plan. Additionally, a particular health plan may
have had different insurers or claims
processors during the time period
encompassed by this questionnaire. Each
option should be listed as a separate group
health plan, even though they all fall under the
umbrella of your organization’s group health
plan.
For example, under an employer’s benefit
program, employees may select from 16
different GHPs. Some of the plans are fee-forservice while others are HMOs or PPOs.
Each option (fee-for-service, HMO/PPO)
should be listed separately. In addition, if the
GHPs are structured in a manner that
hospitalization claims (e.g., major medical) are
processed by one entity and medical services
(e.g., physician services) are processed by a
different entity, each should be listed as a
separate GHP in Part II of the data match report.
Group Health Plan Report Number
We are providing the following format so
that you do not have to repeat the name and
address of your GHP for each identified
individual.
In the left-hand column of Part II Page
1 you will find the GHP Report Number. We
have provided three pre-assigned GHP Report
Numbers (0001-0003) and a second page with
blank GHP blocks to record additional GHPs, if
needed.
If you have had more than six GHPs during the
time period you are required to report, you may
make photocopies of the second page of part II,
then number each additional GHP block in
sequential order.
For example, if your organization is
required to report on all your GHPs since
07/01/1995 and there were 16 plans during
Page 6
that time, you must complete a block for each
plan. The first GHP would be 0001, and the last
would be GHP Report Number 0016.
Part II Page 1 and Part III of the forms
cross-refer based on the GHP Report Number.
Each worker identified in Part III should have a
corresponding Part II GHP Report Number if he
or she has/had a period of coverage. Only use
GHP Report Numbers for workers identified in
Part III. If no workers identified in Part III use
a GHP that you offer, do not include that GHP in
Part II.
Group Health Plan Name
Provide the name of your plan, e.g., XYZ
Insurance, VIP Health Insurance of the United
States, ABC HMO, Union Local #198 Health
Plan, etc. If your GHP is a third-party
arrangement, please provide the name of the
third-party administrator. Only use the name
of your organization in this block if your plan is
self-insured and self-administered.
Group Health Plan Address
Provide the mailing address of your GHP
including street or PO Box, City, State and ZIP
Code as shown in the following example. Please
make sure that this address is the address
where claims are actually filed for covered
individuals, not just the corporate office of the
GHP.
Group Identification Number or Code
Provide the group identification number or
code of the GHP as shown in the following
example. Not all GHPs supply identification
numbers. If you do not have an ID number for
a particular GHP, please leave this space blank.
IMPORTANT NOTE: If the plan you have
listed is organized as a Third Party Administrator (TPA) arrangement under a contract
such that the TPA provides only administrative
services related to claims processing, please
provide the date the entity listed ceased to be
your claims administrator in the space you also
have listed the Group Identification Number or
Code. If the entity continues to be your claims
administrator, please do not provide a date. A
date is required only for TPA arrangements that
DO NOT involve reinsurance, stop-loss, or minimum premium. Remember, you still are
required to complete “Type of GHP”.
GHP Tax Payer ID No.
Provide the TIN of the group health plan.
The vast majority of GHPs are separate legal
entities with unique TINs or which use the TIN
of the employer/sponsor with a unique suffix.
You need to provide the TIN of each GHP.
Pharmacy Benefit International
Identification Number (Rx BIN)
Provide
the
Pharmacy
Benefit
International Identification Number used for
pharmacy routing. All network pharmacy
payers have an Rx BIN. This field is required
when the Coverage Type is U, W, X, or Y.
Pharmacy Benefit Processor Control
Number (PCN)
Provide the Pharmacy Benefit Processor
Control Number used for pharmacy routing.
Some, but not all, network pharmacy payers
use this for network pharmacy benefit routing
along with the BIN. This number, if it is used,
is required when the Coverage Type is U, W, X,
or Y.
Rx Group
Provide the group policy number for the
drug coverage. It may be the same as the
hospital/medical group policy number.
Special Note: If the coverage type your
plan offers includes a prescription drug benefit
that utilizes an electronic (EDI) pharmacy data
network, we require those numbers. Not
everyone using a pharmacy network uses a
PCN, but everyone using a pharmacy network
will have an Rx BIN, so the Rx BIN is always
required when a coverage type of U, W, X or Y
is entered. The PCN should be supplied if your
drug plan uses it.
All Drug payers that process claims
electronically have an Rx BIN, but not all use,
or need to use, a PCN. The only two Rxspecific identifiers that are always required
when reporting a network pharmacy benefit,
indicated by Coverage Type U, W, X or Y, are
the Rx BIN and Rx PCN. But please include all
other Rx-specific information on the record
that your drug plan uses to pay claims, so that
benefits can be efficiently coordinated.
Type of GHP
For each GHP Report Number, please
identify, by a letter from the following table, the
type of plan that best describes the GHP
arrangement provided by your organization.
The options are:
A.
B.
C.
D.
Insurance (Medical and Hospital)
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Third Party Administrator arrangement
under an Administrative Services Only
(ASO) contract without stop loss
insurance from any entity
E. Third Party Administrator arrangement
with stop loss insurance from any entity.
MSP Data Match Project, Instructions for Employers
F. S elf-Insured/Self-Administered
G. Collectively-Bargained Health and Welfare
Fund
H. Multiple employer health plan with at
least one employer who has more than
100 full-time and/or part-time employees
I. Multiple employer health plan with at
least one employer who has more than 20
full-time and/or part-time employees
J. Hospitalization only plan – A plan which
covers ONLY inpatient hospital services.
(e.g., indemnity benefit plans)
K. Medical Services only plan – A plan which
covers ONLY non-inpatient medical
services.
M. Medicare supplemental plan, Medigap,
Medicare wrap-around plan or Medicare
carve-out plan.
U Prescription Drug Only (in network)
V Prescription Drug with Major Medical
(non-network)
W Comprehensive (Hospital, Medical, and
Drug [in-network])
X Hospital and Drug (in network)
Y Medical and Drug (in network)
4 Comprehensive (Hospital, Medical, and
Drug [non-network])
5 Hospital and Drug (non-network)
6 Medical and Drug (non-network)
NOTE: Please do not include retirement/
pension plans, life insurance plans,
dental plans, and or special purpose
indemnity benefit plan (e.g., cancer
plans).
MSP Data Match Project, Instructions for Employers
Page 7
Example
The example to the right provides completed Part II Page 1
information. This employer had three different Group Health
Plans which are being identified by GHP Report 0001, 0002,
and 0003. The first GHP, EMJ Health Insurance plan, is
identified as GHP Report Number 0001. The address, GHP ID
Number or Code and Type of GHP are all provided in their
appropriate boxes in the first section. Similarly, the other two
Group Health Plans are identified in the remaining lines.
Instructions for Completing Part III
You will be supplied with the name and
social security number (SSN) of each individual for whom you are required to
furnish the requested information.
You are requested to provide
information on this Part III form as of a
defined date that is unique to each worker.
The calculation of this date took into account
all applicable MSP laws and regulations.
NOTE: This date will vary for each
worker.
For Question 1, the records indicate
that this individual was employed
by your organization during the years
specified. Please answer either YES the
individual was employed, or NO the
individual was not employed during any of
the specified years.
SPECIAL NOTE FOR RELIGIOUS ORDERS:
Members of religious orders that have taken
a vow of poverty are exempt from the MSP
provisions. This exemption is only
applicable for work being performed
for the religious order. For further
information on religious order exemptions,
please call our toll-free line.
If
the noted employee has taken a vow of
poverty, answer ‘NO’ to question 1. Do not
continue; proceed to the next individual’s
report.
If you answer NO to this question, DO NOT
CONTINUE. Proceed to the next individual
report. If there are no more individual
reports, go to Part IV. Sign the Certification
Statement and return the questionnaire
using the self-addressed mailer or label
provided.
NOTE: The following examples are provided to assist you in completing Part III. The data in these
examples should not be used to complete your employer specific questionnaire.
Example (Question 1):
1. Was this individual employed by your organization during 2004?
•
NO
If the answer to Question 1 is NO, Go to the next individual’s report.
For Question 2, information is requested
regarding whether this individual is currently
employed by your organization. Check the
Page 8
⌧ YES
appropriate box (YES or NO). If the answer
is NO, please provide the date the individual
stopped working for your organization.
IMPORTANT NOTE: If the individual listed
on the report is a re-employed retiree, a
seasonal, temporary, intermittent employee,
MSP Data Match Project, Instructions for Employers
please contact the toll-free line on how to
complete Part III, Questions 1 to 5.
There is a line directly under Question 2. If
the individual listed stopped working for
your organization BEFORE THE DATE
LISTED in this line, DO NOT CONTINUE.
Proceed to the next individual report. If
there are no more individual reports, go to
Part IV. Complete the Certification, sign,
and return the questionnaire using the selfaddressed mailer or label provided.
Example (Question 2):
2. Is this employee currently working full or part-time in your
organization?
If the answer to Question 2 is NO, enter the date the individual
stopped working for your organization (full or part-time) here.
YES
⌧ NO
Month: 05 D
ay: 01 Year: 2004
If this individual stopped working for your organization before *01/01/2001 DO NOT complete Question 3 to 5
*Note: The date given in the above example represents this individual’s, and only this individual’s EPM (Earliest Potential Medicare Secondary
Payer) date. This date will vary for each worker and also appears in Question’s 2,3, and 4.
In the above example, Mr. Steven Grant
worked for the Ace Tire Company from
01/01/2004 (Mr. Grant’s EPM date) to
05/01/2004. The last date of employment
for Mr. Grant was 05/01/2004. This is the
date that should be used as the answer to
Question 2.
The individual may have stopped and
started working several times during the
Data Match reporting period. For the
purpose of answering Question 2, please
provide the most recent date on which the
individual stopped working for your
organization.
For Question 3, information is
requested regarding coverage of the
individual under a Group Health Plan (GHP)
at any time after the specified date. An
example appears below.
There is a line directly under Question
3. If the individual listed was not covered
under your Group Health Plan AFTER the
date listed in this line, DO NOT CONTINUE.
If you answer NO to this question, proceed
to the next individual report. If there are
no more individual reports, go to Part IV.
Complete the Certification and return the
questionnaire using the self-addressed
mailer or label provided.
Example (Question 3):
3.
Was this individual covered under a Group Health Plan at any time
after 01/01/2004?
•
⌧ YES
NO
If this individual was not covered under a GHP after 01/01/2004, DO NOT complete Questions 4 or
5.
Mr. Alfred Green has been employed
with Allstate Construction since 08/15/1998
In every year since then, he has been
covered under the company’s Group Health
Plan. Since Mr. Green’s coverage continued
after the date given, 01/01/2004, the answer
to Question 3 would be “YES”.
Note: The pre-printed date in question 3
may be different for each worker. Please
refer to each individual’s unique pre-printed
date before answering this question.
Question 4a asks you to fill in the LATER of
(1) the date specified on the report, or (2)
the date which the identified individual
started working for your organization. If the
individuals start date is after the pre-printed
date given, use the date they started
working. If they started working prior to
the date given, use the pre-printed date on
their form.
For Question 4b, please enter the
information given in your answer to Question
2. This would be the month, date, and year
the individual stopped working for your
organization. If the individual is currently
working, please use the date that you
prepared this report.
Example (Question 4a and 4b):
5. Please enter in the box marked 4a below, the LATER of 01/01/2004 or the date this individual started working for your
organization. In box 4b, enter your answer from Question 2. If still currently employed, use current date.
MSP Data Match Project, Instructions for Employers
Page 9
4a. Month: 01
Day: 01
Year: 2004
4b: Month: 10
Day: 01
Year: 2004
In the above example the period of
employment for Ms. Grey in Question 4a to
4b was 01/01/2004 to 10/01/2004. In 4a
the employer provided the later of the date
Specified (01/01/2004) or the date Ms. Grey
started working for Ace Pharmacy Company
(03/15/1987). The date Ms. Grey stopped
working (10/01/2004) is the date provided
in 4b. This date also corresponds with the
date entered in Question 2.
For Question 5, information is being
sought regarding the type of GHP coverage
the individual had or still has during the
period between your answer to Question 4a
and Question 4b.
SPECIAL NOTE: However, if you have
certain knowledge that the covered
dependent(s) is someone other than a
spouse (e.g., a dependent child), please
indicate “Worker Only” coverage. The
coverage elected by the worker MUST be
indicated for each period of coverage.
It is recognized that in some situations,
employees will leave employment for
periods of time or be laid off and then
return to work. These periods should be
accounted for in your answer to Question
5. During any interval when the employee
was not covered by a GHP, the coverage
elected should be indicated as “NONE”.
List each period of coverage or noncoverage in chronological order.
In question 5, you will find a table with
periods 1 through 8. Separate periods are
given on this form because the coverage
elected by the employee may have changed
several times between the answers to
questions 4a and 4b.
“Coverage Elected” Definitions:
Worker Only: The worker is the only
individual covered under the GHP.
Family Coverage: The worker and the
spouse are covered under the GHP, indicate
family coverage.
In this section, you will find a table with
period numbers 1 through 8. If you need
more than eight spaces (if the employee had
more than eight types of coverage during the
time period), please photocopy this form
BEFORE completing Question 5. Indicate
that additional periods of GHP coverage were
required, by checking the box marked
“Please check here if this sheet is a
continuation page from the original Part III
form for this employee.”
Please provide information ONLY for the
time between your answer to Question 4a
and Question 4b.
Example (Question 5):
5. During the period of time between your answer to Question 4a and your answer to Question 4b, what type of health coverage did this
individual elect under your plan? If the individual is still employed by your organization, please complete the following from the date listed
in Question 4a to the date in 4b.
Period
Beginning Date
1
2
01/01/2004
03/01/2004
SAMPLE
Ending Date
Coverage Elected (check one box)
Worker Only
Family
None
GHP Report
Number
(Worker & Spouse)
In the previous example, Ms. Grey had
two periods of coverage during the period of
time between 01/01/2004 and 10/01/2004
(i.e., the responses to Questions 4a and 4b).
The first period was from 01/01/2004 to
02/28/2004.
02/28/2004
10/01/2004
X
X
During this period, Ms. Grey elected a
‘Worker Only’ policy. When Ms. Grey
married on 03/01/2004, she elected to
change her coverage to ‘Family’, but the
group health plan remained the same. As
indicated
0002
0002
above, her second period of coverage shows
from 03/01/2004 to the date Ms. Grey
stopped working (i.e., 10/01/2004).
Example (Question 5, when there was a period of no GHP coverage):
You must report the coverage selected by each individual for each period of time. Account for any periods that
the individual was not covered by indicating coverage elected as “NONE”.
Page 10
MSP Data Match Project, Instructions for Employers
Period
Beginning Date
Ending Date
1
2
3
4
01/01/2004
07/01/2004
01/01/2005
06/01/2005
06/30/2004
12/31/2004
05/31/2005
12/31/2005
GHP Report
Number
Coverage Elected (check one box)
None
Worker Only
Family
SAMPLE
(Worker & Spouse)
In the above example, Mr. Kelly had
four periods of coverage identified. For the
first period (01/01/2004 to 06/30/2004) he
elected ‘Family’ coverage under the group
health plan indicated as 0001 on Part II of
the questionnaire. The second period
X
X
X
X
(07/01/2004 to 12/31/2004) shows that he
changed his GHP to 0002. Mr. Kelly then
elected a period of ‘No’ coverage (from
01/01/2005 to 05/31/2005) represented by
the “X” placed in the ‘None’ column. Then,
on 06/01/2005, he elected
0001
0002
0003
‘Family’ coverage, with GHP report number
0003, to the present date (which in this
case, is indicated as 12/31/2005). All
periods between 01/01/2004 (Question 4a)
and 12/31/2005 (Question 4b) are
accounted for in this response.
Example (Question 5, showing coverage under a Collectively-Bargained Health and Welfare Fund):
1
01/01/2005
If the coverage of an employee is through a
collectively-bargained health and welfare fund,
you as an employer may not know the dates of
coverage or type of coverage the employee
elected under the health plan. Therefore, for
those employees covered under these type of
plans, you may complete Part III, Question 5 as
follows:
10/01/2005
?
• For the beginning and ending dates of
coverage, enter your answers from
Question 4.
• Annotate “Coverage Elected” using a
question mark (?).
• Enter the GHP Report Number assigned by
your answers in Part II of the report.
• The name and address of the
collectively-bargained health and welfare
fund should be listed in Part II.
Instructions for Completing Part IV
The individual responsible for completing
the questionnaire must sign and date Part IV,
also neatly printing or typing the person's
name, title, and daytime telephone number.
?
or label provided, or mail to:
Make sure the Privacy Act Statement is
fully reviewed and understood. After the report
is complete, please return the questionnaire
using the self-addressed mailer
MSP Data Match Project, Instructions for Employers
Medicare - Coordination of Benefits
IRS/SSA/CMS Data Match Project
P.O. Box 33848
Detroit, MI 48232-5848
?
0004
Important Note:
As the employer, you are responsible for
following up with the health and welfare
fund to obtain the required information.
However, if you elect to respond using the
question marks as in the example above,
we shall assume that the coverage elected
is Family.
Thank you in advance for your cooperation. If you have any questions concerning the
completion of the forms, please call:
1-800-999-1118 or
(TTY/TDD): 1-800-318-8782
This toll-free number is available from
8:00 a.m. to 8:00 p.m. (Eastern Time), Monday
through Friday.
Page 11
Information on Direct Entry on the IRS/SSA/CMS Data Match Secure Web
Site
Employers, regardless of size, may submit their Data Match questionnaire responses through the IRS/SSA/CMS Data Match Secure Web site using the
Direct Entry option. Direct Entry is a more efficient and timely response method than paper submission. Multiple users at multiple employer
locations can be designated to complete the questionnaires directly online through the use of a personal computer (PC) with Internet access.
WHAT IS DIRECT ENTRY?
Direct Entry is an internet-based option that allows an employer to
complete all Data Match questionnaires directly online via the IRS/SSA/CMS
Data Match Secure Web site, without the need to upload or download files or
complete a paper questionnaire.
Employers assign an Account Manager, who will have the ability to log
into the Secure Web site from any personal computer to complete the
questionnaires, or the Account Manager can designate one or more
employees at one or more employer locations to complete all or specific
parts of a questionnaire.
Data entry screens, modeled after the paper Data Match questionnaire,
are completed directly online, and the information provided is validated for
accuracy and completeness as it is entered. This allows for common errors
to be identified and corrected at the time of submission.
The questionnaire can be completed in one session or saved and
completed at a more convenient time. Users have the ability to view and
print the completed questionnaire data in summary format for up to 30
days from the date of submission. Interactive Web pages and online
documentation take the user through this process effortlessly.
GETTING STARTED
Employers, or their designated representatives, are responsible for
completing the Data Match questionnaire and will be the users of the Data
Match Secure Web site.
There are two user roles on the Web site, Account Manager and
Designee. Only one person may be the Account Manager for an employer,
but there is no limitation on the number of Designees that can be assigned.
The Account Manager is the person who will control the activity related
to the Data Match questionnaire response. He/she is the person who is
responsible for establishing the Employer account on the Web site,
managing the day to day activity related to completing the Data Match
questionnaire, assigning portions of the application to other employees to
complete on the Web site, tracking the status of the tasks assigned to others,
and ensuring questionnaire certification and submission are completed on
time.
The Account Manager is also responsible for inviting other employees
to register on the Web site and managing their access. The Account Manager
may complete and submit the Data Match questionnaire or invite designees
to assist as needed. In many cases, the Account Manager will be a manager
in the employer’s Human Resources Department.
Designees are optional users associated with an employer’s Secure
Web site account who are invited by the Account Manager. These are typically
people who report to the Account Manager in the employer’s Human
Resources Department. The assignment of designees on your account
allows your Account Manager to allocate portions of the Data Match
questionnaire to different staff members for completion. For example, one
Designee may complete the questionnaire for workers in your West Coast
operations center and another for the East Coast operations center.
Designees can also act as a back up to the Account Manager for most of y the
employer’s activity on the site.
Designees will be able to perform all of the functions on the Web
site, including completing and submitting the company’s questionnaire,
Page 12
with the exception of being able to invite additional users. Only the Account
Manager can invite and manage the users associated with an account.
Registering for the Direct Entry (Web Application)
Option
All users must register on the IRS/SSA/CMS Secure Web Site. The
employer must designate an Account Manager who after registering on the
Secure Web site will have the ability to assign designees and start the online
process. When registering, the Account Manager will need the employer
identification number (EIN) and 4-digit personal identification number
(PIN) for each assigned account. The Account Manager must complete a
separate registration process for each EIN. These numbers can be retrieved
from Part I, page 1 of the IRS/SSA/CMS Group Health Plan Report for Data
Match or the Electronic Media Questionnaire Election Form. Your employer
will receive a new PIN for each EIN for each Data Match tax year.
The following describes in general terms how to register as an Account
Manager on the Data Match Secure Web site. Please refer to the Secure Web
Site User Manual, which can be found under the Reference Materials menu
option on www.datamatch.cms.hhs.gov for more information on the use
of this site and step-by-step instructions.
Step 1.
Click on the >> Register as a New Account Manager >> link on the
Login page of www.datamatch.cms.hhs.gov. You will only use this link
once to register. After that, you will use your selected Login ID and Password
to enter the site.
Step 2.
Complete the information on the Account Manager Registration pages
as requested. You will need to provide your e-mail address. During this
process, you will be:
•
•
•
Establishing an account for the employer
Creating your personal Login ID and Password
Indicating the employer’s response method by selecting Direct Entry.
Note that the BBS and EMQ options are not available on the Web site at
this time.
Step 3.
After successful registration, you will see a Thank You page confirming
your registration.
The system will then submit your request to utilize the Secure Web
site. . The selected employer questionnaire data will be available for
processing within 2 business days. If you are unable to access the selected
employer’s questionnaire data within the aforementioned stated timeframes,
please contact the Coordination of Benefits (COB) Contractor at 1-800-9991118 or TTY/TDD: 1-800-318-8782 for the hearing and speech impaired
and a Customer Service Representative will direct your call to someone that
can assist you.
MSP Data Match Project, Instructions for Employers
Note: While the employer’s questionnaire data is being loaded, the Account
Manager may log into the site and invite Designees to register as users and
add accounts for additional EINs as needed.
Registering Additional EINs for the Direct Entry
(Web Application) Option
If you need to complete the Data Match questionnaire for more than
one EIN, you must first complete the Registration process described above.
After successful registration as an Account Manager for a single EIN, you can
then proceed to adding other EINs as described below.
Step 1.
Enter your Login ID and password on the Login page and click Login.
Step 2.
After you accept the Login Agreement, the EIN Listing page will display.
Step 3.
Select Add an EIN on the right-hand side of the page and fill in the
information requested. Your second EIN will appear on the EIN Listing page
after you complete this process.
Need More Information About the Direct Entry
Service?
General information on the Direct Entry option as well as information on
registering for this service is available on the IRS/SSA/CMS Data Match
Secure Web site at www.datamatch.cms.hhs.gov. Information may also
be obtained by contacting our office using our toll free lines: 1-800-9991118 or TTY/TDD: 1-800-318-8782.
MSP Data Match Project, Instructions for Employers
Page 13
Information on the Bulletin Board Service
Employers who are required to complete a questionnaire for less than 500 workers may choose to submit their responses through the Data Match
Bulletin Board Service (BBS). This easy to use personal computer (PC) based feature allows employer’s to download a customized application and
respond to the complete Data Match questionnaire with the use of a dial up modem.
WHAT IS A BBS?
The BBS is a system that users dial up over telephone lines with
computers and modems. It may be used to receive or send files and
messages from the users. In addition, users may be able to receive
files or messages from a BBS system.
GETTING STARTED
You must have an IBM PC or compatible running under Windows 2000
or XP, Microsoft .Net Framework v1.11, MDAC v2.62, a modem (56K bps
or higher) and a communication program to operate your modem.
We strongly recommend using WINDOWS HYPERTERMINAL.
The recommended communication parameter settings are as follows:
8-N-1
8 data bits, no parity, 1 stop bit
ANSI
Terminal Emulation
FULL Duplex
Don't use half duplex
XON/xoff = off
No software flow control
RTS/CTS = on
Enable hardware flow control
Auto-LF = off
Do Not translate a
BS = destructive
The keystroke should
erase what it moves over
Transfer Protocol
Z-Modem
We also recommend that the following disk space allocations be made
for storing and executing the BBS program:
10 MB disk storage space & 256MB RAM.
Signing Up for the BBS
First, notify our office of your decision to use the BBS by calling our
toll free number (1-800-999-1118 or TTY/TDD: 1-800-318-8782) and
utilize the Interactive Voice Response Unit (IVR). The IVR is an interactive
automated referral mechanism that processes requests for information in
regards to the Data Match Project with the use of a touch tone telephone.
The IVR will furnish general information on the Bulletin Board
Service as well as the option of registering for this service. If after listening
to the electronic media information and specifications you decide to
submit responses through the BBS, you can record your decision by
selecting the appropriate menu option.
When selecting the menu option “to register for the BBS” you will be
prompted for your employer identification number (EIN) and 4-digit
personal identification number (PIN). These numbers can be retrieved
from Part I, page 1 of the questionnaire or the EMQ Election Form. The
combination of the EIN/PIN number will also serve as your password when
utilizing the BBS. You may dial into the BBS for your company’s
questionnaire data after five business days.
IMPORTANT NOTE:
1) All new users dialing into the BBS will have to register as a user.
2) After registering as a new user, you will need to call the BBS System
Operator, SYSOP, at (646) 458-6740 to activate your account before
you can download from the BBS.
Logging Into the BBS
Five days after registering to use the BBS, dial into the BBS at (646)
458-6785. After entering your EIN and PIN, you can begin downloading
the questionnaire data, including a customized editing program. The
program will feature interactive prompts, on-line edits and a help facility to
ensure that all the required data is correctly provided.
Downloading Data from the BBS
The entire downloading of the application may take between 45-60
minutes. Please note that this time frame is dependent upon the size of
your questionnaire file and the speed of your modem. Once the
program has been downloaded to your PC, disconnect from the BBS and
execute the program on your PC.
For Users Who Have the BBS Application from the Previous Data Match
Project:
Step 1:
Make a backup copy of last year’s DATAFILE.TXT before beginning to
download the new DATAFILE.TXT for this project year.
Step 2:
Delete the old DATAFILE.TXT from your download folder.
Step 3:
Select “DOWNLOAD INPUT FILE” from the BBS Menu. This is your
new DATAFILE.TXT. Be sure to place this in the same folder as the existing
BBS Executable Application file, BBSV1.EXE, that you downloaded from the
previous project.
Step 4:
Download the file, disconnect from the BBS, and execute the
program on your PC.
For New Users of the BBS Application:
Step 1:
On the BBS Menu, select “DOWNLOAD INPUT FILE” to download the
DATAFILE.TXT. Then select “DOWNLOAD BBS APP” to download the BBS
Executable Application file. You will need to download these files separately
but place them in the same download folder.
Step 2:
Disconnect from the BBS and execute the program on your PC. Once
the application has been successfully executed on your PC, you may begin
completing the Group Health Plan Report.
Completing the Group Health Plan Report:
1
Install package will direct you to the Microsoft Download site
2
Part of the installation package
Page 14
MSP Data Match Project, Instructions for Employers
Review the HELP Section on the Toolbar if you are not familiar with
the BBS. This option contains instructions on how to utilize the bulletin
board service.
Step 1:
The questionnaire data must then be loaded. To load the data:
• Select File from the main menu bar. A pull down menu will appear.
Select Load Data from the list of menu options.
Step 2:
Once the questionnaire data is loaded you may proceed to Part I Employer Information. Please note that all of Part I must be completed
before you can continue.
Step 3:
After Part I is complete, dependent upon the responses provided, Part
II - Group Health Plan Information will need to be completed.
Step 4
When Part II is complete, please proceed to Part III - Employee
Information.
•
Select File from the main menu bar. A pull down menu will appear.
Create File will be listed as one of the menu options.
Please consult this booklet for more explicit instructions and samples
on how to complete the various parts of the Data Match questionnaire.
Uploading Data to the BBS
When you have completed all the questionnaires, dial back into the
BBS to upload your data. The same EIN and PIN combination that was
utilized to initially access the BBS must be entered to upload the
completed data. You may dial in at any time. The service is available 24
hours a day, seven days a week.
Why Use the BBS?
It is simply a more convenient way to submit the Data Match
questionnaire. The BBS will also minimize the need for follow up, because
the customized program provides an on-line editing feature that checks
your responses for completeness and consistency.
If you require assistance once you have entered the BBS, or you
experience any technical problems, contact our Electronic Data
Interchange (EDI) at (646) 458-6740.
Step 5:
A verification must be run after Part I - III have been completed.
Verify validates every data element entered for completeness and
consistency. To execute the verification process:
• Select File from the main menu bar. When this is done a pull down
menu will appear.
• Go to Verify. Another submenu will appear. From this menu select
Run Verify.
• If any errors are detected go to step 7. However, if no errors are
identified you may proceed to step 9.
NOTE: All errors must be corrected before data can be uploaded to
the BBS.
Step 6:
• If you would like to review the errors detected through the verification
process, a report may be run. To run a report:
• Follow step 6 above. However, instead of selecting Run Verify the
appropriate option would be Display Report.
Step 7:
After all the applicable sections of the report have been completed the
next step is the certification (Part IV).
Step 8:
A backup copy of your report should be made before it is
returned to the Data Match Contractor. To process a backup:
• Select File from the main menu bar. A pull down menu will appear.
Backup will be listed as one of the menu options. Once it is selected
a backup will be made of your questionnaire response file.
Step 9:
After steps 1 through 9 have been successfully accomplished, the
completed report may be sent back through the BBS to the Data Match
Center. To send data:
MSP Data Match Project, Instructions for Employers
Page 15
Voluntary Data Sharing Agreements
What Is a Voluntary Data Sharing Agreement?
A Voluntary Data Sharing Agreement is an agreement between the Centers for Medicare & Medicaid Services (CMS) and an insurer or employer to
electronically exchange Medicare and group health plan (GHP) eligibility information. The employer/insurer agrees to share GHP coverage eligibility data
on policy holders/employees and their spouses. In exchange, CMS agrees to provide the employer/insurer with Medicare eligibility information for
identified Medicare individuals. This enables claims to be paid in the correct payer order.
What Is the Purpose of a Voluntary Data Sharing Agreement?
The purpose of the Voluntary Data Sharing Agreement is to more efficiently coordinate health care benefit payments between insurers and Medicare in
accordance with Medicare Secondary Payer (MSP) and Medicare-related laws.
About Employer Voluntary Data Sharing Agreements
The CMS has entered into Voluntary Data Sharing Agreements with numerous Fortune 500 and other large employers. These agreements allow employers
to send and receive eligibility coverage information electronically to and from CMS, producing substantial benefits for these employers. Implementation of
a Voluntary Data Sharing Agreement will allow your organization to receive the following immediate benefits:
•
Elimination of Requirements to Complete Data Match Questionnaires
A Voluntary Data Sharing Agreement is an alternative way for you to satisfy your requirement to Data Match.
•
Improved Timeliness of the Information Being Collected
Instead of completing annual Data Match questionnaires that require you to provide information about employee GHP coverage over the past several
years, you agree to a quarterly electronic data exchange of current GHP coverage information with Medicare.
•
Reduction of Administrative Costs
Instead of handling bulky paper questionnaires, you can send and receive eligibility coverage information electronically to and from Medicare.
•
Elimination of Repayment Claims and Associated Penalties
Voluntary Data Sharing Agreements ensure that all insurers involved in benefits payment, including Medicare, pay primary when appropriate. Paying
correctly first can eliminate the need for overpayment negotiations and possible penalties. Note: Repayment claims arise when Medicare
mistakenly pays primary for services that should have been the primary payment responsibility of your GHP. The CMS may recover from any
entity responsible for making primary payment, including employers. Failure to respond to repayment requests may result in legal action
and/or other collection actions. In addition, under the Debt Collection Improvement Act of 1996, CMS may recover these debts by offsets
against any monies otherwise payable to the employer by the United States, including tax refunds.
•
Reduction in Insurance Costs
Voluntary Data Sharing Agreements clearly identify when Medicare is the secondary payer - and when Medicare is the primary payer to your insurer.
•
Improvement of Service to You and Your Medicare-Entitled Employees
Voluntary Data Sharing Agreements ensure that health insurance claims for the affected beneficiaries are paid correctly by the appropriate primary
payer.
•
Coordination of Part D Prescription Drug Benefits
Data Received from a Voluntary Data Sharing Agreement allows proper billing at pharmacy point-of-sale transactions and is used to facilitate True Out
Of Pocket cost calculation for Medicare beneficiaries enrolled in Medicare Part D.
•
Satisfaction of Retiree Drug Subsidy Reporting Requirements
Using a Voluntary Data Sharing Agreement allows employers claiming the employer subsidy on qualified retirees to fulfill their reporting obligations to
the Retiree Drug Subsidy (RDS) contractor and provides employers with additional Medicare enrollment data that RDS does not.
If your organization is interested in a Voluntary Data Sharing Agreement, please contact our customer service department for additional information
at:
1-800-999-1118, or visit our website: www.cms.hhs.gov/COBGeneralInformation and follow the links to Employer Services.
Page 16
MSP Data Match Project, Instructions for Employers
Insurer Voluntary Agreements as an alternative to an Employer Voluntary Data Sharing Agreements
Employers may also ask their insurer to enter into a Voluntary Data Sharing Agreement on their behalf. Insurer Voluntary Data Sharing Agreements
produce substantial benefits for both employers and insurers that can result in significantly reduced costs for employers related to coordination of benefits
with Medicare. If your organization is unable to participate in the Employer Voluntary Data Sharing Agreement program at this time, we encourage you to
ask your insurer to sign an Insurer Voluntary Data Sharing Agreement with CMS on your behalf.
About Insurer Voluntary Data Sharing Agreements
The CMS currently has Voluntary Data Sharing Agreements with insurers representing over 70% of the health insurance market. Insurer Voluntary Data
Sharing Agreements produce substantial benefits for insurers that can result in significantly reduced costs related to coordination of benefits with Medicare.
Implementing an Insurer Voluntary Data Sharing Agreement will allow insurers to obtain the following immediate benefits:
•
Elimination of Need to Complete Medicare Secondary Payer Questionnaires
A Voluntary Data Sharing Agreement is an alternative way for you to provide GHP data to CMS. Currently, when you learn that you are primary to
Medicare, you must report this information to CMS by submitting an MSP questionnaire or contacting the Coordination of Benefits (COB) Customer
Service Department. Voluntary Data Sharing Agreements allow you a way to automate the submission of this information and submit it on a regularly
scheduled basis.
•
Compliance with Third Party Payer’s Notice of Mistaken Medicare Primary Payment
Under Code of Federal Regulations (CFR) 411.25, insurers are required to notify Medicare if they have made a primary payment for services for
which the insurer should have made primary payment. Voluntary Data Sharing Agreements help prevent insurers from making inappropriate
secondary payments, largely eliminating the need for this notification.
•
Improvement of Service to Your Medicare-Entitled Subscribers
Voluntary Data Sharing Agreements ensure that health insurance claims for the affected beneficiaries are paid correctly by the appropriate primary
payer. The electronic exchange ensures that both Medicare and the insurer obtain accurate and timely information. By exchanging Medicare and GHP
information, both parties can coordinate payment and ensure that bills are sent to the right payer. This will prevent delays in the claims payment
process and help reduce beneficiaries’ out-of-pocket expenses.
•
Improvement of Service to Employers
Employers are required by law to provide GHP information on their Medicare-eligible employees, and spouses of Medicare-eligible employees,
through the IRS/SSA/CMS Data Match. If you are an insurer, you can streamline your employer client’s processing of Data Match information and
ensure their employees’ records are up-to-date by entering into a Voluntary Data Sharing Agreement. Voluntary Data Sharing Agreements reduce
administrative costs and eliminate duplication of effort.
•
Improvement in the Administration of Insurance
Voluntary Data Sharing Agreements ensure that all insurers involved in benefits payment, including Medicare, pay primary when appropriate.
Voluntary Data Sharing Agreements identify not only when Medicare is the secondary payer, but also when Medicare is the primary payer. You may
not always know if the policy holder/subscriber or their spouse has Medicare. Additionally, you may lack the information to determine primacy or
may be confused by the MSP laws and regulations pertaining to End Stage Renal Disease (ESRD). ESRD rules can be complicated, but clear ESRD
status data is provided to insurers and employers in the Voluntary Data Sharing Agreement data exchange. It can also be difficult to determine if
subscribers have entitlement to Medicare due to disability. Even if you recognize that the beneficiaries are entitled, you may not know if Medicare is
primary because of employment status and other issues. Voluntary Data Sharing Agreements will allow you to be notified when Medicare becomes
primary for these beneficiaries.
•
Automation of Data Exchange
Voluntary Data Sharing Agreements offer you the ability to electronically exchange information on inactive (non-working covered) individuals. The
inactive file exchange is a valuable benefit to insurers because it allows you the ability to query Medicare for a high volume of specific inactive
individuals. This process can be automated with the right programming. Through this automated process, you can query the same beneficiary (or set
of beneficiaries) each time you send an inactive file (every 6 months). We will then respond to your inquiry with the individuals that are now
Medicare eligible.
•
Elimination of repayment claims and associated penalties
Voluntary Data Sharing Agreements allow you to coordinate health care benefit payments more efficiently in accordance with Medicare-related laws.
Agreements ensure that all insurers involved in benefit payments, including Medicare, pay primary when appropriate. In some instances, other
insurance is available to pay for furnished services and Medicare payment is secondary to the payment obligation of the other insurance. If Medicare
makes a mistaken primary payment in such a situation, Medicare pursues recovery of the mistaken primary payment from the insurer. Voluntary
Data Sharing Agreements help to ensure that claims are paid right the first time, eliminating the need for overpayment negotiations and associated
penalties and interest charges. Note: The CMS may recover from any entity responsible for making primary payment, including the insurer.
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Failure to respond to repayment requests may result in legal and/or other collection actions. In addition, under the Debt Collection
Improvement Act of 1996, CMS may recover these debts by offsets against any monies otherwise payable to the insurer by the United States,
including tax refunds.
•
Coordination of Part D Prescription Drug Benefits
Data received from a Voluntary Data Sharing Agreement allows proper billing at pharmacy point-of-sale transactions and is used to facilitate True Out
Of Pocket cost calculation for Medicare beneficiaries enrolled in Medicare Part D.
•
Satisfaction of Retiree Drug Subsidy Reporting Requirements
A Voluntary Data Sharing Agreement allows employers claiming the employer subsidy on qualified retirees to fulfill their reporting obligations to the
Retiree Drug Subsidy (RDS) Center and provides employers with additional Medicare data that RDS does not. An insurer can submit employer files to
the RDS Center via their Voluntary Data Sharing Agreement.
If your insurer is interested in a Voluntary Data Sharing Agreement, please have them contact our customer service department for additional
information at:
1-800-999-1118 or visit our website: www.cms.hhs.gov/COBGeneralinformation and follow the links to Insurer Services.
How Do Voluntary Data Sharing Agreements Work?
The employer/insurer and CMS enter into a contract to exchange Medicare and GHP information. Before beginning file exchange, CMS and the
employer/insurer discuss data requirements, file submissions, and any other issues. Test files are exchanged enabling CMS to ensure that all files are
readable and free of errors. Once the testing is complete, the employer/insurer sends an MSP file containing coverage information for active
employees and their spouses as well as employer/insurer Tax Identification Numbers (TIN). The MSP file submission identifies individuals that are
Medicare beneficiaries for whom Medicare assumes secondary payment responsibility. The employer/insurer sends a separate Non-MSP file
containing retirees and their covered spouses. The Non-MSP file submission identifies individuals for whom Medicare assumes primary payment
responsibility or for whom the employer is claiming the employer subsidy offered by Medicare.
How Can I Obtain a Copy of a Voluntary Data Sharing Agreement?
The CMS has tasked the COB Contractor with the responsibility for consolidating activities that support the collection, management, and reporting of
all other health insurance coverage of Medicare beneficiaries. As such, the COB Contractor implements the IRS/SSA/CMS Data Match and assists CMS
in establishing Voluntary Data Sharing Agreements by providing an information packet and customer service.
For more information on a cost and time saving alternative to the traditional IRS/SSA/CMS Data Match process, and for methods for data collection and
sharing for your organization, please contact us at:
Centers for Medicare & Medicaid Services
Data Sharing Agreement Program
c/o Coordination of Benefits Contractor
P.O. Box 660
New York, NY 10274-0660
Or call: 1-800-999-1118 or TTY/TDD: 1-800-318-8782 for the hearing and speech impaired, Monday through Friday, from 8:00 a.m.
to 8:00 p.m., Eastern time, except holidays, and ask the Customer Service Representative about Voluntary Agreements.
You can also visit our web site at: www.cms.hhs.gov/COBGeneralinformation and follow the links to Employer or Insurer
Services.
Example Pages.
The following pages demonstrate completed questionnaires of fictitious companies named Pitstop Inc. and Jack’s Cafe. The
completed forms are broken up into four reporting parts to provide you with a full set of examples.
DO NOT use the dates provided in these examples to complete your individual questionnaire. You must refer to the actual
IRS/SSA/CMS Data Match Questionnaire file that you receive and your company’s own personnel, payroll, and benefits records, in order to
determine the specific dates you must provide when completing the report. The pre-printed dates on each questionnaire are referred to
as EPM (Earliest Potential Medicare Secondary Payer) dates. This date may vary from employer to employer and, even within a single
employer, from worker to worker.
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MEDICARE - Coordination of Benefits
NOTES
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MEDICARE - Coordination of Benefits
NOTES
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42 USC 1395y(b)(5)
Identification of Secondary Payer Situations
(A) REQUESTING MATCHING INFORMATION. –
(i) COMMISSIONER OF SOCIAL SECURITY. -- The Commissioner of Social Security
shall, not less often than annually, transmit to the Secretary of the Treasury a list of the
names and TINs of Medicare beneficiaries (as defined in section 6103(l)(12) of the
Internal Revenue Code of 1986) and request that the Secretary disclose to the
Commissioner the information described in subparagraph (A) of such section.
(ii) ADMINISTRATOR. -- The Administrator of the Health Care Financing
Administration (renamed Centers For Medicare & Medicaid Services 6/14/01) shall
request, not less often than annually, the Commissioner of the Social Security
Administration to disclose to the Administrator the information described in
subparagraph (B) of section 6103(l)(12) of the Internal Revenue Code of 1986.
(B) DISCLOSURE TO FISCAL INTERMEDIARIES AND CARRIERS. -- In addition to any
other information provided under this title to fiscal intermediaries and carriers, the
Administrator shall disclose to such intermediaries and carriers (or to such a single
intermediary or carrier as the Secretary may designate) the information received under
subparagraph (A) for the purposes of carrying out this subsection.
(C) CONTACTING EMPLOYERS. -(i) IN GENERAL. -- With respect to each individual (in this subparagraph referred to
as an "employee") who was furnished a written statement under section 6051 of the
Internal Revenue Code of 1986 by a qualified employer (as defined in section
6103(l)(12)(D)(iii) of such Code), as disclosed under subparagraph (B), the appropriate
fiscal intermediary or carrier shall contact the employer in order to determine during
what period the employee or employee's spouse may be (or have been) covered under a
group health plan of the employer and the nature of the coverage that is or was provided
under the plan (including the name, address, and identifying number of the plan).
(ii) EMPLOYER RESPONSE. -- Within 30 days of the date of receipt of the inquiry, the
employer shall notify the intermediary or carrier making the inquiry as to the
determinations described in clause (i). An employer (other than a Federal or other
governmental entity) who willfully or repeatedly fails to provide timely and accurate
notice in accordance with the previous sentence shall be subject to a civil money penalty
of not to exceed $1,000 for each individual with respect to which such an inquiry is
made. The provision of section 1128A (other than subsections (a) and (b)) shall apply to
a civil money penalty under the previous sentence in the same manner as such
provisions apply to a penalty or proceeding under section 1128A(a).
V17.052406.445M
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| File Type | application/pdf |
| File Title | Microsoft Word - DMXIII Instruction Booklet COBSW Direct Entry Changes2trackchg 080201.doc |
| Author | Mark |
| File Modified | 2008-02-28 |
| File Created | 2008-02-26 |