New Medicare Rule

introduction to new medicare rule

New government reporting requirements affect all employers with health plan coverage, regardless of whether they have any Medicare-eligible employees. To help coordinate benefits for Medicare beneficiaries, The Centers for Medicare & Medicaid Services now require all insurance carriers and all administrators of self-insured plans to report the following information pertaining to your group plan:

  • The size of your group, according to CMS counting rules
  • Your tax identification number
  • Social Security numbers of Providence Health Plan subscribers and dependents

These new rules are outlined in Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007. The new law puts in place fines of $1,000 per day per member for instances of noncompliance. An employer's Providence Health Plan enrollment may be affected if we do not receive information required for this reporting.

Groups must submit complete information to Providence Health Plan

All groups, administrators and producers have received a letter describing these new reporting requirements. The letter outlines three convenient ways for a group to submit this information:

  • Using a prepopulated electronic spreadsheet
  • Social Security numbers through Electronic Data Interchange (EDI) (and employer tax ID and CMS group size via a data submission form available by request)
  • Social Security numbers through our online billing and enrollment function (and employer tax ID and CMS group size via a data submission form available by request)

Not yet registered for online billing and enrollment? This is a great opportunity for employers to make the switch. Learn more.

How does CMS define "group size"?

CMS determines group size as the current total number of nationwide full-time employees, part-time employees, seasonal employees and partners. Do not count retirees, COBRA-qualified beneficiaries and individuals on other continuation options, or self-employed individuals who participate in the employer's group health plan.

It is important that you count the total number of employees for all entities on the tax return.

For complete information about secondary payer rules and how CMS determines group size, consult The Centers for Medicare & Medicaid Service's Medicare Secondary Payer Manual (PDF).

For more information

For complete information about new reporting requirements for all health plans and their employer clients, visit the CMS Mandatory Insurer Reporting page for group health plans.