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What to Know About Medicare Secondary Payer Rules and CMS Data Match Program

Have you received a CMS Data Match Questionnaire letter? Contact Clearpath Benefits and Consultants for assistance through the process.

Learn more about UBA’s most recent webinar covering Medicare Secondary Payer Rules and the CMS Data Match Program.

Medicare Secondary Payer Rules

Medicare is a secondary payer for many individuals who have an employer group health plan available to them, either as an employee or the dependent spouse or child of the employee. The CMS Data Match Program was implemented to enforce these rules.

Why would an Employer get a Data Match Letter?

The purpose of the Data Match Program is to identify situations where primary insurance should pay before Medicare. Employers who receive a Data Match questionnaire from the federal government are required to complete it.

The questionnaire requests group health plan information on identified individual employees or spouses of employees and are entitled to Medicare or married to a Medicare beneficiary. Employers must respond within 30 days of the initial inquiry, unless an extension has been requested and approved.

3 Pieces of Advice from the Experts and How Clearpath Can Help:

  1. Make sure that as an employer, your benefits consultant, insurance carrier, and CPA are aware of Secondary Payer Rules.
  2. Also, be aware that there are additional steps to follow when providing for an employee with End Stage Renal Disease (ESRD).
  3. Finally, know that if you receive a Data Match Questionnaire and you don’t know what to do with it, Clearpath is here to work with you and provide current and past clients access to a Compliance Manager who is experienced in these cases.

Tom-Rubino-140x200Clients have been receiving demand letters from collectors. But many people don’t know what they are to do with them so they contact us,” said Thomas Rubino, partner and consultant.

Unfortunately, it often takes several years for Medicare to complete an audit and send a letter to the employer. Some employers have changed carriers or benefit options or are self-funded and have closed out the year to which the Medicare claim applies.

In response to the letters, our team at Clearpath assists our clients in taking a proactive approach to replying. We are able to coordinate with the insurance companies to get the needed information,” continued Rubino.


Bill-Shimp-140x200With only 30 days to reply to the demand letter, it is important to have someone to assist with gathering the extensive data requested. Compliance managers who have expansive knowledge about the ends and outs of this industry can help you insure that you cover all your bases.

Just last week we helped someone who is a past client respond to a letter they received by looking up plan information and the data the letter mandates they provide,” said Bill Shimp, partner and consultant.

Are you an employer with 20+ employees? (Including full AND part time!) Here is what you need to know.

  1. You are subject to the Medicare Secondary Payer rules.
  • Employers with 20 or more employees, including full and part-time, are subject to MSP rules. Employees who are not enrolled in the group plan count.
  1. Once you qualify, even if you drop below 20 employees, you are still responsible.
  • You’ll be responsible for offering primary coverage for the remainder of that year and throughout the next year.
  1. As an employer, you cannot take into account the Medicare eligibility of an employee when it comes to benefits.
  • This includes failing to pay for primary benefits or having higher premiums or longer waiting periods for Medicare-eligible participants
  1. This also includes offering incentives.
  • Generally, the Medicare Secondary Payer rules prohibit employers with more than 20 employees from in any way incentivizing an active employee age 65 or older to elect Medicare instead of the group health plan, which includes offering a financial incentive.

Are you an employer with <20 employees?

In a business with less than 20 employees, Medicare is primary. Be sure to take the time to ensure that everyone 65 and older, and on the employer’s Medicaid plan has enrolled in part A and part B Medicare. The insurance companies will assume the employee has enrolled and coordinate benefits accordingly.


Download your copy of our experts’ advice.

To see the specific UBA employer webinar that our experts discussed click Here.

To download the specific UBA employer webinar click Here.