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Printed Date: 9/22/2015
The "working aged" are employed people age 65 or over, and people age 65 or over with employed spouses of any age, who have group health plan (GHP) coverage because of their own or their spouse's current employment.
Medicare is secondary payer to group health plans for the "working aged" where either:
If a single employer with fewer than 20 employees sponsors or contributes to a plan, Medicare is the primary payer for all working aged people enrolled in the plan. Also, if an employee organization, such as a union, is associated with an employer of fewer than 20 employees and sponsors or contributes to a plan, Medicare is the primary payer for all working aged people enrolled in the plan.
The "20 or More Employees" Threshold
The "20 or more employees" threshold is met when an employer has 20 or more full and/or part-time employees for each working day in each of 20 or more calendar weeks in the current calendar or preceding calendar year. The 20 calendar weeks do not have to be consecutive. This requirement is based on the number of employees, not the number of people covered under the plan. Group health plans assure correct application of the "20 or more employees" rule by taking the following steps:
Multiple Employer and Multi-Employer Plans
The Medicare Secondary Payer requirements for the working aged apply to both multiple employer plans and multi-employer plans. A multiple employer plan is a plan sponsored by more than one employer. A multi-employer plan is a plan jointly sponsored by employers and unions under the Taft-Hartley law. (Under multi-employer plans, an employer typically pays a premium based on the hours that a union employee works. The premium is paid into a special health and welfare fund that administers benefits.)
Employers must follow the Internal Revenue Service aggregation rules to determine whether the "20 or more employees" threshold is met.
If a GHP wishes to exempt such employees of a particular employer from the Working Aged provision because the employer does not meet the "20 or more employees" requirement, the following documentation must be submitted:
If all the above information is not included, the GHP should be asked to provide the information required before Palmetto GBA can process claims as the primary payer.
CMS Regulation Reference: Publication 100-05, Chapter 1 (PDF, 195 KB).
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Last Updated: 10/08/2019