Employers Medicare resources

Coverage, coordination of benefits for Medicare Parts A & B

General information

There are a few ways people become eligible for Medicare. The most common are: 

• Age
• Disability
• End-stage renal Disease (ESRD)

The employer and/or employee are responsible for advising Prevea360 Health Plan of any eligibility and/or enrollment in Medicare Part A or Part B, regardless of the reason for that enrollment. Failure to do so may cause delays or incorrect claim processing.

Enrollment

Enrollment in a Prevea360 Health Plan group policy is based on an employee’s current employment status at the time he or she qualifies to enroll (actively at work, retired, COBRA or severance). 

The Social Security Administration (SSA) and Prevea360 Health Plan follow the same guidelines to determine employees’ Medicare eligibility. Use the Medicare summary charts to identify when employees are “working” and “not working” to determine if enrollment in Part B is advisable to reduce the employee’s out-of-pocket expenses. The only exception to this rule is if the employee is covered under Medicare’s ESRD program.

An employee cannot be forced to enroll in any part of Medicare. However, per an employer's Member Certificate, Prevea360 Health Plan will pay as if the employee was enrolled, which means the employee will incur out-of-pocket expenses for amounts that Medicare would likely have paid.

If an employee is getting ready to enroll in any non-actively-working segment, such as retiree, COBRA, continuation, long term disability (LTD), severance or other “non-working” status while covered by the employer’s plan, remind the employee to review his or her responsibility to enroll in Medicare, if eligible. Employees may check on their Medicare eligibility by contacting the local SSA office or by calling our Medicare Coordination of Benefits (COB) Analyst for assistance. The contact numbers are in the Medicare section of this document.

If the employee contacts the SSA office, he or she should be prepared to give as much detail as possible concerning his or her planned retirement or termination from work. This may include the employer size, his or her work status and the work status of his or her spouse. Any paperwork the employer can furnish indicating the member’s retirement/termination may prevent delayed or denied medical claims.

Regardless of circumstances, it is ultimately the employer and/or the employee’s responsibility to ensure Prevea360 Health Plan is made aware of Medicare eligibility and enrollment, for any reason.

If the employer or employee is unsure when Medicare enrollment is advisable to avoid out-of-pocket expenses, please call the Medicare COB Analyst at the number indicated at the end of this section.

See our retiree information

Employer group size

Employer group size is determined by the number of employees on the payroll records for the prior IRS calendar year as indicated in the Medicare Secondary Payer Manual. Prevea360 Health Plan will be the primary payer only when required by federal regulations.

The “working” and “not working” charts below display the criteria that SSA uses when determining beneficiary eligibility and whether we will be the primary payer before Medicare. It is very important for coordination purposes that the employer report accurate employee numbers to Prevea360 Health Plan on the Group Information Form sent each year for renewal, or the Employer Application for Group Coverage Form when initially enrolling with Prevea360 Health Plan.

Medicare secondary payer manual, chapter 2 indicates:

10.3 - The 20-or-more employees requirement:

This rule applies if an employer has 20 or more full time and/or part-time employees for each working day in each of 20 or more calendar weeks in the current or preceding year.

30.2 - The 100-or-more employees requirement: 

This rule applies to employers that employed 100 or more full-time and/or part-time employees on 50 percent or more of its business days during the previous calendar year.

Medicare is secondary for all employees enrolled in a multi-employer plan, such as a union plan which covers employees of some small employers as well as employees of at least one employer that meets the 100-or-more employee requirement, including those that work for small employers. There is an exception to the working aged provision, as it does not apply to the payment order determination if the employee is enrolled in Medicare due to a disability. An employer will be considered to employ 100 or more employees on a particular day if the employer has at least 100 full-time or part-time employees on his/her employment payrolls on that day, regardless of the number of employees who work or who are expected to report for work on that day.

Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 established mandatory reporting requirements for group health plans. All group health plans, including Prevea360 Health Plan, are required to comply. 

Each December, we send you a form requesting information about your group size for the current year. Prevea360 Health Plan is required to report this information to CMS, so it is essential that the form is completed accurately and promptly returned. It is the employer's responsibility to notify Prevea360 Health Plan immediately if the group size changes from fewer than 20 to 20 or more employees for 20 weeks or more (the weeks do not have to be consecutive).

Each May (which is 20 weeks into the year) we send a reminder notice is sent to Groups that reported fewer than 20 employees in the previous year, to help groups remember to report a change to 20 or more employees. The reminder notice must be returned if the Group has increased the number of employees to 20 or more for 20 or more weeks (the weeks do not have to be consecutive) since Jan. 1 of the current year. 

Medicare questionnaire

Each month, Prevea360 Health Plan sends a Medicare Questionnaire to employees who are about to reach the age of 65. This is sent to members approximately 60 days prior to the member’s birth date.

Each letter is specific to the employee's current work status and is personally addressed to that individual. If no response is received within 30 days, a second request is sent. If no response is received from the second request, we will complete a review using the Medicare Data Match through the Centers for Medicare and Medicaid Services (CMS). We will update its system based on the information obtained through CMS. In cases where information is not provided, the information from Medicare will take priority. By State law, if we have on record that you employ 19 or fewer individuals, you will also receive a copy of this questionnaire. 

Prior to a Medicare Demand Letter, the Coordination of Benefits & Recovery Center (CRC) will send a Primary Payment Notice (PPN) to both the impacted employer and the insurer/TPA (Third Party Payer). The PPN is a notice to the employer to advise them that the Centers for Medicare & Medicaid Services (CMS) has identified instances where Medicare may have mistakenly made a primary payment when other primary insurance exists. Enclosed with this notice is a PPN worksheet that lists Medicare beneficiaries and corresponding coverage dates. The notice requests the employer to review the worksheet, make corrections and additions as necessary, and mail or fax the completed worksheet to the CRC.

Medicare demand letters - refund requests

These requests are sent to the last employer known to Medicare. These requests are sent as a result of a possible debt that may be owed to Medicare because it may have mistakenly paid primary for medical claims Prevea360 Health Plan should have paid. These requests are extremely time sensitive and require immediate action by the employer. If the response to these requests is not received by Medicare within 60 days from the date of the initial request, interest is added and is accrued monthly. Medicare does not make allowances for postal service delays. 

If you receive a Medicare demand letter and the individual concerned was insured with Prevea360 Health Plan, contact our Medicare COB Analyst to ensure Prevea360 Health Plan has received a copy. We review all claims sent, make payments as necessary and ensure the employer receives a copy of the final disposition of that request.

If the employee is insured by Prevea360 Health Plan, it is your responsibility to ensure that we are advised of all such letters. If you have any questions about these requests, call our Medicare COB Analyst at 608-827-4189.

After Medicare completes its review, it will respond with a letter indicating no further payment is required and the “case is closed,” or it will request additional information or payment.

Failure to comply with the federal laws concerning these refund requests can make the employer group responsible for the amount due. In addition, if there is any delay determined as “inappropriate” by Prevea360 Health Plan, the employer group may be liable for any interest accrued from that delay.

Failure to notify us of Medicare eligibility resulting in claim reversals and premium changes

If the employee/dependent fails to inform the employer or Prevea360 Health Plan that they are eligible for Medicare, the situation will be reviewed and action may be taken. We have the legal right to recover funds paid incorrectly when information of this type is discovered.

• The specific employee will be notified by letter of this change to the primary payer of the medical claims and given the reasons and dates in question.
• The employee/dependent will also be referred to the nearest SSA office to consult about possible options available.

Medicare premiums will only apply if Medicare is the primary payer regardless if the member is enrolled in Medicare Part B.

Medicare eligibility summary charts

Employee who is currently working

Employee who is not currently working

Due to ACA regulations Small Employer Groups do not receive rate adjustments for Medicare primary members.

Coverage for individuals with End-Stage Renal Disease (ESRD) does not vary with employer group size or active work status of the individual or spouse. The employee should contact the SSA for more information.

These guidelines do not reflect all the possible criteria affecting the primary payer determination. For further details, contact the Social Security Administration.