2025 Annual MSP Employer Attestation

Under federal Medicare Secondary Payer (MSP) laws, HMSA is required to collect certain information about the size of each of its employer groups to help ensure proper coordination of benefits. We also use this information to comply with related MSP reporting requirements, which includes information about members enrolled in group health plans (GHP) who are also entitled to Medicare. HMSA will update your records according to the information you submit in the attestation.

We rely on you to report group size changes in a timely and accurate manner to ensure compliance with federal law. If any information you previously provided is inaccurate or you have reason to believe a past or present primacy designation may be incorrect, please report these discrepancies to your account representative as soon as possible.

If you don’t complete the MSP attestation by the due date, the Centers for Medicare & Medicaid Services (CMS) requires us to set your GHP to pay primary for members who are:

Entitled to Medicare based on their age and have a GHP based on their own or a spouse’s current employment status.
Entitled to Medicare based on a disability and have a GHP based on their own or a family member’s current employment status.

Please note that once the deadline is missed, we may be unable to reverse or update your group size information until the next annual attestation period.

If you have any questions or concerns about the attestation or your legal obligations under the MSP laws, please consult your legal advisers.

1) Employer's legal name (the "company")

2) Company’s nine-digit Federal Employer Identification Number/Tax Identification Number (FEIN/TIN)

3) Company’s nine-digit HMSA group number, which can be found on your bill

4) Was the company in business in 2025?

Yes

5) Did the company have 20-99 employees (including full-time, part-time, and seasonal employees) for each working day in at least 20 consecutive or nonconsecutive weeks during 2025?*

Yes

6) Please enter the date that the 20 employees/20 week threshold was met in 2025

7) Did the company have 100 employees or more (including full-time, part-time, and seasonal employees) on at least 50% of its business days during 2025?*

Yes

8) Please indicate the date of your evaluation

(Note: If your answers to any question in the attestation change for any reason you must immediately notify your account representative to help ensure proper coordination of benefits.)

9) Is your health plan obtained, sponsored, contributed to, or in any way facilitated by an association, professional employer organization (PEO), multiple employer welfare arrangement (MEWA), or a combination of one or more employers and employee organizations (e.g., a union or Taft-Hartley plan), or another third-party group?

Yes

10) Provide the name of the association or organization

*Employer size must be based on the total number of all employees in a company’s organizational structure, including the employees of all subsidiaries and affiliates that are part of the company’s “controlled group” under the IRS’s employer aggregation rules. For additional information, consult 42 C.F.R. § 411.106. The employee count must include any employee (worldwide) who is either (a) actively working or (b) not actively working but meets certain MSP regulatory requirements. The latter category includes, among others, furloughed workers and individuals on short-term disability. For additional information, consult 42 C.F.R. § 411.104.

By typing my name in the “e-signature” field and clicking “Submit form” below, I attest that I am an authorized representative of the company. I hereby certify that the information I am providing in this MSP employer attestation is complete and accurate to the best of my knowledge, information, and belief. I understand that HMSA will rely on this information in processing claims for enrollees in the company’s group health plan and that the company has an obligation to update HMSA promptly regarding changes to the information provided. I acknowledge that HMSA will update the company’s records according to the information I have submitted in the attestation.

e-signature

Title

Your email

Phone number

This information is a high-level summary and for general information purposes only. This information is not comprehensive and does not constitute legal, tax, compliance, or other advice. To understand how this applies to you, please seek the advice of independent legal counsel.

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