R2000-207 AUTHORIZING APPLICATIONS

Home Browse Search

which has at least one participating employer that employs 100 or more employees, the MSP rules apply even with respect to employers of fewer than 100 employees. The rules for calculating the size of the employer are complicated, and vary depending on numerous factors. In determining whether the size threshold has been met in any giv- en case, the MSP statute and regulations must be consulted. Application of the statute depends not only on the size of the employer but also, in certain cases, on whether the coverage provided under the GHP is based on "current employ- ment status," as defined in the MSP statute and regulations. 2. The Non-Discrimination Provisions: Age and Disability: The MSP statute prohibits GHPs from"take[ing] into account"that an individual covered by virtue of"current employment status"is entitled to receive Medicare benefits as a result of age or disability. The statute expressly requires GHPs to furnish to aged employees and spouses the same benefits, under the same conditions, that they furnish to em- ployees and spouses under age 65.Thus, GHPs may not offer coverage that is second- ary to Medicare under a provision that"carves out"Medicare coverage(commonly known as a "carve-out" policy), or which supplements the available Medicare coverage (com- monly known as"Medicare supplemental" or"Medigap" policies), to individuals covered by the provisions of the MSP statute relating to the working aged and the disabled. By ' contrast, "Medigap" and secondary health care coverage may appropriately be offered , to retirees in this context because the GHP coverage is not based on "current employ- ' ment status," and thus the MSP provisions do not apply. , 3. ESRD: The MSP statute also prohibits a GHP from taking into account that an individual is en- titled to Medicare benefits as a result of ESRD during a coordination period specified in the statute. This coordination period begins with the first month the individual becomes �, eligible for or entitled to Medicare based on ESRD and ends 30 months later. During this , period, the GHP must pay primary for all covered health care items or services, while � Medicare serves as the secondary payer. GHPS are prohibited from offering second- � ary (i.e., "carve-out") and "Medigap" coverage in this context. , 4. Em lo er Obli ations: ! p Y 9 It is the obli ation of the Em lo er to ensure that Covered Persons covered b the MSP , 9 P Y Y statute are not improperly enrolled in"carve-out"or"Medigap"coverage under this Agree- I, ment. � B. The New Information System , Improved Information Gathering: ' In an effort to facilitate the processing of claims consistent with the requirements of the MSP '� statute, and to assist in meeting the statutory obligations, certain BlueCross and BlueShield ' Plans together with the Health Care Financing Administration ("HCFA"), the federal govern- , ment agency which administers Medicare, are developing or have developed a new enroll- ment and membership system.The system, also referred to as the"Data Match,"is aimed at I�, obtaining, in a timely and current fashion, information necessary for the Claim Administrator ' to identify dual coverage situations which fall within the MSP statute, and to determine wheth- I ' ' er primary or secondary payment should be made for a particular claim. I Under the system,the Claim Administrator will provide basic information to HCFA about indi- �i viduals enrolled in GHPs who are also covered by Medicare so that HCFA can better detect �� dual coverage situations. - 13 - ��