How does a sponsor resolve any discrepancy between its plan rules and the Medicare Secondary Payer (MSP) rules with regard to whether any individual is an active employee for purposes of the ERRP?
With respect to the Early Retiree Reinsurance Program, the U.S. Department of Health & Human Services (HHS) will generally defer to a plan’s rules to determine whether a given individual is an active employee. Such plan rules should be a written plan document, published and in effect as of the day a claim for health benefits for an individual was incurred for which the sponsor seeks credit toward the $15,000 cost threshold or reimbursement, that indicates whether or not the individual in question is an active employee for all plan purposes. Absent such a document, or in situations in which the plan rules regarding the definition of active employee are vague and unclear, the determination of whether an individual is an active employee for purposes of the program, is determined by whether such individual is considered to be receiving coverage by reason of current employment status under the MSP rules at 42 C.F.R. 411.104 and related Centers for Medicare & Medicaid Services’ guidance.
With respect to the Early Retiree Reinsurance Program, the U.S. Department of Health & Human Services (HHS) will generally defer to a plan’s rules to determine whether a given individual is an active employee. Such plan rules should be a written plan document, published and in effect as of the day a claim for health benefits for an individual was incurred for which the sponsor seeks credit toward the cost threshold or reimbursement, that indicates whether or not the individual in question is an active employee for all plan purposes. Absent such a document, or in situations in which the plan rules regarding the definition of active employee are vague and unclear, the determination of whether an individual is an active employee for purposes of the program, is determined by whether such individual is considered to be receiving coverage by reason of current employment status under the MSP rules at 42 C.F.R. 411.104 and related Centers for Medicare & Medicaid Services’ guidance.
Related Questions
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