Who Pays First if More Than 20, Less Than 100

[somarco]

In the past when I have looked this up for a client the reference I found mentions less than 20 employees or 20+ as the break point for group health and Medicare.

Yesterday I found a new source and saw this.

CMS certainly goes out of their way to make it confusing.



If your employer has fewer than 20 employees, Medicare generally pays first.

But if your employer joins with other employers or employee organizations (like unions) to sponsor a group health plan (called a multi-employer plan), and any of the other employers have 20 or more employees, Medicare would generally pay second.

Your plan might also ask for an exception, so even if your employer has fewer than 20 employees, you'll need to find out from your employer whether Medicare pays first or second.

Generally, if your employer has fewer than 100 employees, Medicare pays first if you're under 65 or you have Medicare because of a disability.

Sometimes employers with fewer than 100 employees join with other employers to form a multi-employer plan or multiple employer plan. If at least one employer in the multi-employer plan or multiple employer plan has 100 employees or more, Medicare pays second.

If the employer has at least 100 employees, the health plan is called a large group health plan. If you're covered by a large group health plan because of your current employment or the current employment of a family member, Medicare pays second.

If you go outside your employer plan's network, it's possible that neither the plan nor Medicare will pay

https://www.medicare.gov/supplement...first/which-insurance-pays.html#collapse-2446

 

[kgmom219]

In the past when I have looked this up for a client the reference I found mentions less than 20 employees or 20+ as the break point for group health and Medicare.

Yesterday I found a new source and saw this.

CMS certainly goes out of their way to make it confusing.

If your employer has fewer than 20 employees, Medicare generally pays first.

But if your employer joins with other employers or employee organizations (like unions) to sponsor a group health plan (called a multi-employer plan), and any of the other employers have 20 or more employees, Medicare would generally pay second.

Your plan might also ask for an exception, so even if your employer has fewer than 20 employees, you'll need to find out from your employer whether Medicare pays first or second.

Generally, if your employer has fewer than 100 employees, Medicare pays first if you're under 65 or you have Medicare because of a disability.

Sometimes employers with fewer than 100 employees join with other employers to form a multi-employer plan or multiple employer plan. If at least one employer in the multi-employer plan or multiple employer plan has 100 employees or more, Medicare pays second.

If the employer has at least 100 employees, the health plan is called a large group health plan. If you're covered by a large group health plan because of your current employment or the current employment of a family member, Medicare pays second.

If you go outside your employer plan's network, it's possible that neither the plan nor Medicare will pay

https://www.medicare.gov/supplement-other-insurance/how-medicare-works-with-other-insurance/who-pays-first/which-insurance-pays.html#collapse-2446

Every group is now required to complete some type of Medicare Secondary Payor form, in somr fashion. Some carriers do it at enrollment, BCBS does it annually, some carriers use the "yes or no" box for COBRA, etc. However, if there is any confusion, the client can call their HR person (or in a 20 and under group, whoever is completing the form) OR the group carrier. Customer Service can answer this one.

And if you think this is confusing, you should see the MSP form the employers have to decipher...

 

[somarco]

Sheeeutttt!

When did this take place? Didn't think I took that long of a nap.

you should see the MSP form the employers have to decipher..

And you probably have a link, right?

 

[kgmom219]

Here you go................

 

[DS4]

https://www.cms.gov/Medicare/Coordi...Secondary-Payer/Medicare-Secondary-Payer.html

 

[somarco]

Thanks Jen & Dayton. But Dayton's link has a qualifier that the person is disabled. Link above makes no mention of a disabling condition.

Maybe SAI knows. He is the real expert around here.

 

[kgmom219]

Thanks Jen & Dayton. But Dayton's link has a qualifier that the person is disabled. Link above makes no mention of a disabling condition.

Maybe SAI knows. He is the real expert around here.

From a practical perspective..

Who the heck is employed AND getting SSDI at the same time?

 

[somarco]

Who the heck is employed AND getting SSDI at the same time?

I refuse to answer on the grounds I may be heckled.

But if they were a dependent covered by a group plan with more than 20 employees but less than 100 and some of the other employers in that same group were Democrat voters who only go to church on Saturday then Medicare will be the secondary payer.

 

[senior-advisor-indiana]

Thanks Jen & Dayton. But Dayton's link has a qualifier that the person is disabled. Link above makes no mention of a disabling condition.

Maybe SAI knows. He is the real expert around here.

I would answer but I need 217 more useless posts before I add a valuable one. I don't want to screw up my ratios...

 

[yorkriver1]

The answer to these questions is "hidden" in plain sight in the chart on page 26 of the 2017 Medicare and You. Pretty good chart, very clear. https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf

Re: who works and has SSDI: Spouse could be on SSDI. Employed SSDI recipients can work and earn limited amounts. Surely there are people working the system, but people who have been in accidents that weren't their fault, or have degenerative nerve diseases are not collecting disability because they are lazy or faking it.