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Survey Help

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.

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Frequently Asked Questions (FAQs)

What is Medicare Secondary Payer (MSP)?

This is the term generally used when Medicare is not the primary payer for a health care claim. It means another entity has the primary responsibility to pay a claim before Medicare pays. The decision as to who is responsible for paying first on a claim and who pays second is also known as “coordination of benefits.” MSP provisions apply to group health plans (GHP).

Why is HMSA asking me to complete this survey?

To comply with federal MSP regulations, HMSA must collect information about the size of each of its employer groups. This information will help us ensure that we’re complying with CMS reporting obligations and are coordinating health plan benefits appropriately for your employees who are eligible for Medicare.

Do I need to complete this survey if none of my employees are eligible for Medicare?

  • Yes. Even if you don’t have any employees who are eligible for Medicare at this time, HMSA is required to collect this information on an annual basis.
  • HMSA is responsible for working with CMS to keep this information up to date for all our employer groups.

Why does HMSA need this information?

We’re required by law to collect this information and share it with CMS to make sure that we’re coordinating health plan benefits appropriately for your employees who are eligible for Medicare.

What happens if I don’t complete the survey or I miss the deadline?

  • If you don’t complete the MSP survey by the due date, CMS requires us to set your group plan to pay primary for members who are:
    • Entitled to Medicare based on their age and have a group plan based on their own or a spouse’s current employment status.
    • Entitled to Medicare based on a disability and have a group plan 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 survey period.

Who do I include in my total employee count?

Please include the number of full-time, part-time, and seasonal employees that your business had globally. Employer size must be based on the size of the entire company or corporation, not just the local subsidiary.

How will employers that are part of a multi-employer group know if they are considered a small or large group?

  • When an employer is part of a multi-employer group plan, all groups under the multi-employer will need to have less than 20 employees in order to be considered small.
  • If at least one of the groups has 20 or more employees, all groups under the multi-employer group will be treated as having 20 or more employees. The group health plan will pay primary for Medicare-entitled members 65 or older who are covered under the GHP due to their current employer or spouse’s current employer.
  • If at least one of the groups has 100 or more employees, then all groups under the multi-employer group will be considered a “large employer.” The GHP will pay primary for Medicare-entitled members 65 or older or under 65 and disabled who are covered under the GHP through current employment or a family member’s current employment.

What does it mean for members if their employer has less than 20 employees?

It means that Medicare pays first and GHP coverage pays second for Medicare-entitled members who fall into both of the following categories:

  1. The member is either 65 or older or under 65 and disabled, and
  2. The member is covered under a GHP through their own current employer or a family member's current employer.

What does it mean for members if their employer has 20 or more employees?

For Medicare-entitled members 65 or older who are covered under a GHP through current employment or spouse’s current employment, Medicare pays second and GHP pays first.

What does it mean for members if their employer has 100 or more employees?

For Medicare-entitled members 65 or older or under 65 who are disabled and covered under a GHP through current employment or a family member’s current employment, Medicare pays second and GHP pays first.

When do I need to report changes to my employee size to HMSA?

Timely and accurate notification of group size changes ensures that HMSA is complying 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.

What is a small employer exception?

  • CMS offers a program for employer groups who have fewer than 20 employees but are part of a multi-employer group health plan (at least one group with 20 or more employees). The multi- or multiple employer plan or authorized insurer should submit all requests for exceptions directly to the Benefits Coordination and Recovery Center (BCRC).
  • The exception would only be granted for specifically named and approved beneficiaries associated with a specifically named employer group under the multi-employer group plan.

Common terms and definitions

  • Employer: An individual (person or organization) that pays another individual (an employee) a salary, wage, and/or other benefits in exchange for the employee’s work or services. An employer can also be any individual acting directly as an employer or indirectly in the interest of an employer in relation to an employee benefit plan. (See ERISA § 3(5); 42 Code of Federal Regulations (CFR) § 411.101.)
  • Employee: An individual who is working for an employer or is not working for an employer but is receiving certain payments subject to FICA taxes or would be subject to FICA taxes except that the employer is exempt from those taxes under the Internal Revenue Code. (See 42 CFR § 411.104.)
    • Examples of an individual not considered to be an employee are:
      • Self-employed sole proprietor
      • Partner in a partnership
      • Retiree
      • COBRA-qualified beneficiary
    • For more information on whether an individual should be considered an employee for purposes of MSP, please contact CMS or consult with your attorney.
  • Current employment status: For purposes of Medicare Secondary Payer rules, an individual has current employment status if the individual is actively working as an employee, is the employer, or is associated with the employer in a business relationship.
    • An individual 65 years or older still has current employment status if they are not actively working and is on short-term or long-term disability or sick leave from an employer, is still carried on the employer’s employment rolls, and the individual has employment-based group health plan coverage that is not COBRA coverage. (See 42 United States Code (USC) § 1395y(b)(1)(E)(ii); 42 CFR 411 § 411.104; see also CMS Medicare Secondary Payer Working Aged course [PDF].)
  • Group health plan (GHP): A plan, including self-insured plans, of or contributed to by an employer, including a self-employed person or employee organization to provide health care to employees, former employees, the employer, others associated or formerly associated with the employer in a business relationship, or their families. (See 26 USC § 5000(b)(1); see also 42 USC § 1395y(b)(1)(A)(v).)
  • Multi-employer or multi-employer GHP: Any trust, plan, association, or any other arrangement that is sponsored jointly by two or more employers (sometimes called a multiple employer plan) or by employers and unions (as under the Taft-Hartley law). (See 42 CFR § 411.101.)

CMS Resources

Medicare Secondary Payer Overview
Medicare Secondary Payer Manual
Medicare Secondary Payer Fact Sheet [PDF]
Small Employer Exception