Form CMS-R-137 DMI

MEDICARE - Coordination of Benefits
1- 800-999-1118 or (TTY/TDD): 1-800-318-8782

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 a Data Match report. The law requires you to
complete this Data Match report within 30 days of receipt of your Data Match Personal Identification
Number (PIN). Failure to complete the 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 employer group health
plans, providers of medical services to Medicare beneficiaries, and the Medicare program. Employers
benefit 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.

•

Submission options provided through the IRS/SSA/CMS Data Match Secure Web site are 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 or the Electronic Media Questionnaire
(EMQ) program, which is designed for those employers with the largest number of working Medicare
beneficiaries or their spouses, refer to page 14 of this booklet.

•

If you are interested in an alternative to completing the Data Match questionnaire response via the
IRS/SSA/CMS Data Match Secure Web site, refer 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 your Data Match
report. Information on the types of questions you will complete is also provided.

ADDRESS:
MEDICARE – Coordination of Benefits
IRS/SSA/CMS Data Match Project
P.O. Box 660 New York, N.Y. 10274-0660
Web site: www.cms. gov/COBGeneralinformation

TELEPHONE:
1-800-999-1118
or (TTY/TDD): 1-800-318-8782

P.O. Box 660 • New York • NY• 10274-0660
(A CMS Contractor)

IRS/SSA/CMS DATA MATCH QUESTIONNAIRE
Quick Reference Guide for Employers
To complete the Group Health Plan Report, access the Coordination of Benefits (COB) Contractor IRS/SSA/CMS Data Match Secure
Web site at www.datamatch.cms.hhs.gov. You will need the 4 digit Personal Identification Number (PIN). This number can be found
on your Data Match notification mailing. For further information and assistance, please call our toll-free number: 1-800-999-1118 or
(TTY/TDD): 1-800-318-8782.

Questionnaire Part I

• 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.
• 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 complete the Certification
information.
• For further information on this part of the questionnaire,
please continue to page 7 of this booklet.

Questionnaire Part II

• NOTE: Complete 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.
• 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 EMQ Submitters only: In Part II Each GHP identified
must be given a single and unique report number. 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 further information on this part of the questionnaire,
please continue to page 8, and 9 of this booklet.

Questionnaire Part III
•

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.

Questionnaire Part III cont’d

• If you answer "NO" to Question 3, STOP, DO NOT
CONTINUE. Proceed to the next individual 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."
• NOTE: If the individual identified is or was covered by a
collectively bargained health and welfare fund, go to page 12 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 10through 13.

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 13.

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)
Important Notice on Potential Health Insurance Costs Reduction
(OBRA 93 Transition Process for Disabled Medicare Beneficiaries) ............................................................ 1
Important Information Regarding Employers and the New Mandatory Insurer Reporting Law) ................... 3
GENERAL INFORMATION
How to Complete the Data Match Questionnaires .......................................................................................... 4
Instructions for Completing Part I ................................................................................................................... 6
Instructions for Completing Part II .................................................................................................................. 7
Instructions for Completing Part III ................................................................................................................ 9
Instructions for Completing Part IV .............................................................................................................. 12
Information on the IRS/SSA/CMS Data Match Secure Web Site ................................................................. 13
Information on Voluntary Data Sharing Agreements .................................................................................... 17
42 USC 1395y(b)(5) IDENTIFICATION OF SECONDARY PAYER SITUATIONS ...................................................... 18
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 v on the IMPORTANT
WARNING FOR EMPLOYERS).

Page ii

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 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 selfinsured 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 parttime 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

MSP Data Match Project, Instructions for Employers

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 totals 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.
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 individuals.
See
page 4 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.
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;
• To assure that their plans do not
discriminate against employees
and employees’ 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

MSP Data Match Project, Instructions for Employers

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.
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 or
facilitate or subsidize a plan
intended only to supplement
Medicare’s benefits. Employer
plans may, however, offer them
Page iii

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.

•

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

•

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

For all people with permanent
kidney failure, with or without
Medicare, both during and after the
30-month period, the plan may not:

•

charge a higher premium than it
charges to other enrollees in the
plan.

•

refuse to allow an individual with
permanent kidney failure to enroll,
or to re-enroll, 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,

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).

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.

Page iv

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. 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

MSP Data Match Project, Instructions for Employers

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.

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 non-conforming
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.

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).

MSP Data Match Project, Instructions for Employers

Page v

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 nonworking 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

Page 1

MSP Data Match Project, Instructions for Employers

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 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) 1-800-3188782.

Page 2

MSP Data Match Project, Instructions for Employers

Important Information Regarding Employers and the New Mandatory Insurer
Reporting Law
Section 111 of the Medicare, Medicaid, SCHIP Extension Act of 2007 requires group health plan arrangements to report
information that the Secretary of the Department of Health and Human Services requires for purposes of coordination of
benefits. In general, group health plan reports are submitted by the plan’s insurer or claims processing party administrator
(TPA). The law also imposes this same requirement on liability insurers (including self-insurers), no-fault insurers, and
workers’ compensation laws or plans. In order for Medicare to properly coordinate Medicare benefits, Medicare requires the
collection of the beneficiary’s Health Insurance Claim Number (HICN) or Social Security Number (SSN) and the federal
Employer Identification Number (EIN) of the employer, along with other pertinent insurance information.

SECTION 111 REPORTING CRITERIA
Insurers and claims processing TPAs are a reliable source to obtain group health plan (GHP) and large group health plan
(LGHP) information. These insurers and claims processing TPAs, known for Section 111 reporting purposes as Responsible
Reporting Entities or RREs, are required by law to report specific information on GHP and LGHP coverage to CMS on a
quarterly basis for all individuals where Medicare is the secondary payer.
The insurers and claims processing TPAs must report GHP and LGHP information on all individuals meeting the definition of
an active covered individual. For purposes of Section 111 reporting, active covered individuals are:
•
•
•
•

All individuals covered in a GHP or LGHP age 45 through age 64 who have coverage based on their own or a family
member’s current employment status.
All individuals covered in a GHP age 65 and older who have coverage based upon their own or a spouse’s current
employment status.
All individuals covered in a GHP who have been receiving kidney dialysis or who have received a kidney transplant,
regardless of their own or a family member’s current employment status.
All individuals covered in a GHP or LGHP who are under age 45, are known to be entitled to Medicare, and have
coverage in the plan based on their own or a family member’s current employment status. The Health Insurance Claim
Number (HICN) must also be submitted.

HOW EMPLOYERS CAN ASSIST
The HICN or SSN and Employer Identification Number (EIN) are required data elements for Section 111 reporting because
they are necessary for Medicare to properly coordinate benefits. Your insurers or claims processing TPAs may request this
information, and other data related to an insured individual, if that information is not on their files. The CMS encourages
employers to work with their insurers and claims processing TPAs and assist them, as necessary, in obtaining the information
needed for mandatory reporting compliance.

THE BENEFIT OF EMPLOYER COOPERATION
•
•
•

•

Prompt employer cooperation with its GHP and LGHP insurers, or TPAs, will reduce GHP and employer costs
associated with the coordination of benefits with Medicare.
Prompt employer cooperation with its GHP and LGHP insurers, or TPAs, will prevent Medicare from making mistaken
payments. Fewer mistaken payments made by Medicare will result in fewer recovery actions against employers.
Your participation in enhancing the efficiency of obtaining this important information could reduce, or even possibly
eliminate, the need for employers to provide insurance information via the IRS/SSA/CMS Data Match questionnaires. If
CMS determines that the MMSEA Section 111 mandatory reporting requirements process is successful, CMS will
consider requesting that Congress eliminate current employer responsibilities under the annual IRS/SSA/CMS Data
Match.
If an employer does not provide its GHP and LGHP insurer, or TPA, the information necessary and required for Section
111 reporting, the employer is placing its GHP and LGHP insurer, or TPA, at risk for non-compliance with Section 111
reporting requirements.

If you would like further information on mandatory insurer reporting requirements, please visit the CMS Web site at
www.cms.gov/mandatoryinsrep.

MSP Data Match Project, Instructions for Employers

Page 3

General Information
How to Complete the Data Match Questionnaires
In late 1989, a law was enacted
(Section 6202 of the Omnibus Budget
Reconciliation Act of 1989) to provide
CMS with better information about
Medicare beneficiaries’ group health
plan coverage.
The law requires the IRS, the
Social Security Administration (SSA),
and CMS to share information that
each agency has about whether
Medicare beneficiaries or their spouses
are working. The process for sharing
this information is called the
IRS/SSA/CMS Data Match.
The purpose of the Data Match is
to identify situations where another
payer may be primary to Medicare.
The Data Match identifies
employers of beneficiaries for whom
employer coverage, if available, is
likely to be primary to Medicare. The
law requires that CMS contact these
employers to confirm coverage
information. Your compliance with this
law will identify potential situations in
which Medicare is not the primary
payer.
This publication is intended to
assist and guide you through the timely
completion of the Data Match Project
(DMP) Questionnaire, Parts I, II, III
and IV. You should read through the
entire instruction booklet and review
your data match report before you
begin to complete the report.
Depending on your organization’s
answers to the questions in Part I, it
may not be necessary to complete Parts
II and III. It is extremely important
that all instructions are carefully and
closely read and that all answers to the
questionnaires provided by you are
accurate.
Applicable
Federal
MSP
requirements are found in Section
1862(b) of the Social Security Act (42
U.S.C. Section 1395y(b)) and at 42
C.F.R. Part 411 (1990). You should
verify that your group health plan is in
conformity with these Federal
requirements. This instruction booklet
clarifies the procedures for completion
Page 4

of these questionnaires. However, it is
not a legal document. The official
Federal requirements are contained in
the relevant laws, regulations, and
rulings.
NOTE: If you participate in a
collectively-bargained health and
welfare fund or a multiple employer
plan, it may be necessary for you to
contact the plan administrator to
complete some of the sections of this
report. Please do so early enough to
assure that you will comply with the
time frame stipulated in the law for
completion of these questionnaires.
For example, you may need to contact the plan administrator to find out if
there is one employer in the plan that
has or has had 20 or more full-time
and/or part-time employees during the
years listed on your data match report.
Also, you would need to find out if
there is one employer who has/had 100
or more full-time and/or part-time
employees in any year listed on your
data match report. DO NOT ask the
plan administrator if there is/was an
employer with 20 or 100 individuals
eligible for coverage or covered under
the plan. The requirements of the law
are based on the number of employees,
not the number of individuals eligible
for coverage or covered under a plan.
This report may look different from
other reports you are required to
submit to the government. A major
difference is that certain worker
information
has
already
been
completed for you. This identified
worker information is the result of the
IRS/SSA/CMS Data Match process.
You should note that these individuals
were identified because either the
worker or the worker’s spouse is/was a
Medicare beneficiary.
Any employer that has multiple
Employer Identification Numbers
(EINs) and would like all data sent to
one central location for response may
arrange for this. The request must be
made in writing, to our post office box
address noted below. Please inform all

entities in your organization that you
are making this request.
The law requires that you complete
the enclosed report within 30 days.
Employers who willfully or repeatedly
fail to report, or who provide
inaccurate or incomplete information,
may be assessed a civil monetary
penalty of up to $1,000 for each
individual for whom an inquiry
concerning health care coverage was
made.
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): 1800-318-8782.
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 660
New York, NY 10274-0660
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;

MSP Data Match Project, Instructions for Employers

•
•
•

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.

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.

MSP Data Match Project, Instructions for Employers

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): 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
employee’s 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.
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.
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.

Page 5

Personal Identification Number
(PIN):
This number appears on the Data
Match notification letter. It is a 4
digit number that is used by
employers
to
access
the
IRS/SSA/CMS Data Match Secure
Web site.
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 1-800999-1118 or (TTY/TDD): 1-800-3188782.

Page 6

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.
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.

MSP Data Match Project, Instructions for Employers

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 includes full time, parttime,
i n t e r mi t t e n t
and/or
seasonal employees)?
For each of the years listed, check
YES or NO as to whether your
organization participated in a multior multiple-employer 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 5 of this booklet
or call our toll-free number 1-800999-1118 or (TTY/TDD): 1-800318-8782.
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. Proceed to Part
IV and fill in the Certification
information. (Only Parts I and IV will
need to be completed).
Question 4: In the following
years, did you have 100 or more
employees during 50% of your
business days full or part-time)?

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.
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 multiemployer 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 Disease
b eneficiar ies
or
d isab led
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.

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 multior multiple-employer Group Health
Page 7

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.
The Data Match will require health
coverage information for specific
Medicare-eligible workers and/or
spouses
of
Medicare-eligible
individuals identified in Part III of
this questionnaire. Please note that the
employer is only required to report
on those group health plans that
supplied coverage for the workers
identified in Part III of the
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-for-service 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
Page 8

match report.
Group Identification Number or
Code
Provide the group identification
number or code of the GHP.
Type of GHP
Below is a listing of the various
types of GHP arrangements.
EMQ SUBMITTERS ONLY: 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.
A. Insurance (Medical and Hospital)
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 noninpatient medical services.
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 [nonnetwork])
5 Hospital and Drug (non-network)
6 Medical and Drug (non-network)

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 if
your plan is self-insured and selfadministered.
Group Health Plan Address
Provide the mailing address of
your GHP including street or PO Box,
City, State and ZIP Code. 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.
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.

NOTE: Please do not include
retirement/ pension plans, life
insurance plans, dental plans, and or
special purpose indemnity benefit
plan (e.g., cancer plans).
GHP Tax Payer ID No.
Provide
the
Taxpayer
Identification Number (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.
Group Health Plan Name

MSP Data Match Project, Instructions for Employers

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 Rx-specific 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 Rxspecific information on the record that
your drug plan uses to pay claims, so
that benefits can be efficiently
coordinated.
Remember only the GHPs for the
individuals identified in Part III of the
questionnaire must be reported.

MSP Data Match Project, Instructions for Employers

Page 9

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 for Part III of the
questionnaire 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’s report. If there
are no more worker reports, go to
Part IV to complete the Certification
Statement.

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 2008 or 2009?
If the answer to Question 1 is “Yes,” continue to question 2.
If the answer to Question 1 is NO, go to the next worker’s report.

For Question 2, information is
requested regarding whether this
individual is currently employed by
your organization.
Check the
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 reemployed
retiree,
a
seasonal,
temporary, intermittent employee,
please contact the toll-free line on
how to complete Part III, Questions 1
to 5.
If you answered No to Question
2, you must furnish a Stop Date,
which would be the last day the

employee worked. If the last day
worked is before the worker's EPM
(Earliest Potential Medicare) date,
you do not have to furnish any
additional information on this worker.
DO NOT CONTINUE. Proceed to
the next individual’s report. If there
are no more individual reports, go to
Part IV to Complete the Certification.

Example (Question 2):
2. Is this employee currently working in your organization?
If the answer to Question 2 is NO, enter the date the individual stopped working for your organization (full or parttime).
If this individual stopped working for your organization before *01/01/2008 DO NOT complete Questions 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.

For Question 3, information is
requested regarding coverage of the
Page 10

MSP Data Match Project, Instructions for Employers

individual under a group health
plan (GHP) at any time after the
specified date.
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.

If the individual listed was not
covered under your Group Health
Plan AFTER the individual’s EPM
date, 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
and complete the Certification.
For example, Mr. Steven Grant
worked for the Ace Tire Company
from 01/01/2008 (Mr. Grant’s EPM
date) to 05/01/2008. The last date
of employment for Mr. Grant was
05/01/2008. This is the date that
should be used as the answer to
Question 2.

Example (Question 3):
3.

Was this individual covered under a Group Health Plan at any time after 01/01/2008?
If this individual was not covered under a GHP after 01/01/2008, DO NOT complete Questions 4 or 5.

For Question 3, information is
requested regarding coverage of the
individual under a group health
plan (GHP) at any time after the
specified date.
If the individual listed was not
covered under your group health
plan AFTER the individual’s EPM
date, DO NOT CONTINUE. If you

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
individual’s start date is after the pre-

answer NO to this question,
proceed to the next individual’s
report.
If there are no more
individual reports, go to Part IV
and complete the Certification.
For example, Mr. Alfred Green
has been employed with Allstate
Construction since 08/15/2002. In

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

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, 01/01/2008, the
answer to Question 3 would be
“Yes.”

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):
4. Please enter in the box marked 4a below, the LATER of 01/01/2008 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.

For example, Ms. Grey started
working for ACE Pharmacy
Company March 15, 2008 and
stopped working on October 1,

MSP Data Match Project, Instructions for Employers

2009. The date listed in question
4a would be 03/15/2008, the Later
of the date specified (01/01/2008).
The date Ms. Grey stopped
working,

10/01/2009, would be provided in
Question 4b. This date also would
correspond with the date entered in
Question 2 for Ms. Grey.

Page 11

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.
Consider full time, part time,
intermittent, and seasonal employees
when answering Question 5. Provide
an answer for each year listed.
Periods of coverage for each
GHP are required, including type of
coverage offered. Indicate Worker
Only coverage if the worker is the
only individual covered. Indicate
Family coverage if the worker and
spouse are covered under the plan.
Account
coverage.

for

any

breaks

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
mployee was not covered by a GHP,
the coverage elected should be
indicated as “NONE”. List each
period of coverage or non-coverage
in chronological order.

child), please indicate “Worker Only”
coverage. The coverage elected by the
worker MUST be indicated for each
period of coverage.
Please
provide
information
ONLY for the time 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

in

For each period of coverage the
following information is required:
−
−
−
•
•
•
−

Beginning date of coverage
Ending date of coverage
Coverage Type
Worker
Family
None
GHP Name

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.

For example, Ms. Grey had
two period of coverage during the
time between 03/15/2008 and
10/01/2009, (i.e., the responses to
Questions 4a and 4b). The first
period was from 03/15/2008 to
06/30/2008.
During

this period, Ms. Grey elected a
‘Worker Only’ policy. When Ms.
Grey married on 07/01/2008, she
elected to change her coverage to
‘Family’, but the group health plan
remained the same. Her first period

of coverage from 03/15/2008 to
06/30/2008 would show Worker
Only coverage, and her second
period of coverage would be from
07/01/2008 to 10/01/2009, which is
the date Ms. Grey stopped working.

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”.
If Ms. Grey had two periods of coverage but a lapse between the two, such as Worker Only coverage from 03/15/2008 to
04/30/2008, no coverage from 05/01/2008 to 06/30/2008, and Family (Worker & Spouse) coverage from 07/01/2008 to
10/01/2009, then, three periods of coverage would be reported to list all periods of coverage between 01/01/2008 (Question
4a.answer) and 10/01/2009 (Question 4b.answer).

Page 12

MSP Data Match Project, Instructions for Employers

Period
1

Beginning Date
03/15/2008

Ending Date
04/30/2008

2
3

05/01/2008
07/01/2008

06/30/2008
10/01/2009

MSP Data Match Project, Instructions for Employers

Coverage
Worker
Only
None
Family

Page 13

Instructions for Completing Part IV
Part IV Certification asks the employer to verify that the information being provided is complete and correct to the best of their
knowledge. This section must be completed because it serves as a certification that the data is valid.
If you have any questions concerning the completion of this questionnaire, please contact the Coordination of Benefits Customer
Service Department at 1-800-000-1118 or (TTY/TDD) 1-800-318-8782. This toll-free number is available Monday through Friday,
from 8:00 a.m. to 8:00 p.m. Eastern Time.

Page 14

MSP Data Match Project, Instructions for Employers

Information on the Coordination of Benefits (COB) Contractor IRS/SSA/CMS Data
Match Secure Web Site
Data Match questionnaire responses are submitted through the IRS/SSA/CMS Data Match Secure Web site. There are two
submission options available via the Secure Web site: Direct Entry and Electronic Media Questionnaire (EMQ).
Direct Entry is an efficient and timely response method. 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.
Employers with at least 50 workers for whom they must report may submit their Data Match questionnaire responses using the
Electronic Media Questionnaire (EMQ) option. The Electronic Media Questionnaire (EMQ) program is designed to assist larger
employers by allowing them to respond to the questionnaire via electronic media rather than manually completing the information
through the Direct Entry method. Employers with less than 50 workers should use the Direct Entry method.

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 download or upload files.
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 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.
What is the Electronic Media Questionnaire (EMQ)
option?
The EMQ method is available to employers with at least 50
workers for whom they must report. Employers choosing this
method will download a file of the workers via the
IRS/SSA/CMS Data Match Secure Web site, and upon
completion of the questionnaire response file, return to the
Secure Web site and upload the data.
Those employers who choose to participate in the EMQ
program will have certain responsibilities regarding the
availability of media, the ability to develop simple software
applications, and the availability of a few personnel. EMQ
submitters will be required to register on the Secure Web site to
submit their file response through the EMQ application. The
employer will first download the worker file from the Secure
Web site and develop software to create the Data Match
Questionnaire response file. Upon completion, the response
file is uploaded to the Secure Web site.
This method is the best choice for those employers who
have hundreds of worker records to complete within a limited
timeframe. The IRS/SSA/CMS Data Match Project Electronic

MSP Data Match Project, Instructions for Employers

Media Questionnaire (EMQ) Specifications for Employers
booklet provides information on the EMQ program
specifications, including employer eligibility requirements and
the technical aspects of preparing an EMQ data file response.
Please review this booklet, which is available on the
IRS/SSA/CMS Data Match Secure Web Site at
www.datamatch.cms.hhs.gov.

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, including downloading and
uploading files for the EMQ response method, 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

Page 15

Account Manager for most of 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, 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 Web Application
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 the Data Match notification
letter received. 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.

Registering Additional EINs
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 or EMQ
Options?
General information on the Direct Entry and EMQ options
as well as information on registering for this service is available
on the IRS/SSA/CMS Data Match Secure Web site at
Information may also be
www.datamatch.cms.hhs.gov.
obtained by contacting our office using our toll free lines: 1800-999-1118 or TTY/TDD: 1-800-318-8782.

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
either Direct Entry or EMQ
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 1-800-999-1118
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.
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.

Page 16

MSP Data Match Project, Instructions for Employers

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
employer to electronically exchange Medicare and group health plan (GHP) eligibility information. The employer agrees to share
GHP coverage eligibility data on policy holders/employees and their spouses. In exchange, CMS agrees to provide the employer
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.
•

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. 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 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.
•

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

MSP Data Match Project, Instructions for Employers

Page 17

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 Web site: www.cms.hhs.gov/COBGeneralInformation and follow the links to Employer
Services.

Page 18

MSP Data Match Project, Instructions for Employers

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

MSP Data Match Project, Instructions for Employers