Medicare Secondary Payer Attestation for New Groups

If the company has 20-99 employees* (including full-time, part-time, and seasonal employees), was it for each working day in at least 20 (consecutive or nonconsecutive) calendar weeks during the current year?

Yes

Enter the date that the 20 employees/20 calendar week threshold was met:

Was the company in business the previous calendar year?

Yes

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) calendar weeks during the previous year?

Yes

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

Yes

Is your health plan being 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 other third-party group?

Yes

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 signing, 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.

This information is a high-level summary and for general informational 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.

Medicare Secondary Payer Attestation for New Groups

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