Medicare Secondary Payer Rules Notice

UPMC Health Plan has updated its 2021 Certificates of Coverage (COC) for commercial group products with new language that reflects our approach to Coordination of Benefits for members eligible for Medicare as the primary payer of benefits.

UPMC Health Plan will be sending information this week to all employer groups that will renew in the last 6 months of 2021 and have less than 20 employees. The primary contact of these accounts will receive a Medicare Secondary Payer Letter and Employer Attestation Form. It is extremely important that the attestation is filled out completely and sent back to UPMC Health Plan within 30 days of receipt.
We’ve also created this helpful Medicare Secondary Payer FAQ document to help you prepare for any questions you may receive from your employer groups.

The Certificates of Coverage for our fully insured group products and level-funded ASO* (Administrative Services Only) groups will include the following provision: If you are eligible for Medicare but do not enroll and maintain Medicare Part B coverage, UPMC Health Plan will follow the Medicare Secondary Payer Regulations and coordinate the benefits payable for Covered Services under this Certificate of Coverage as if you were enrolled in Medicare Part B. This means we will calculate payment by taking into account the benefits that would have been paid under Medicare Part B had you enrolled.

Traditional ASO groups may opt out of including this language. For ASO groups that delay their decision on MSP language, we recommend it be added on the next renewal date.

Under the Medicare Secondary Payer rules, when Medicare is primary, UPMC Health Plan will pay the claim as if Medicare coverage is in place. In calculating our benefit, we will estimate Medicare’s benefit as the primary payer if a member did not purchase Original Medicare or a Medicare Advantage plan. Making this change helps to allow UPMC Health Plan to continue offering competitive premium rates, while also providing an opportunity for ASO groups to lower their claims expenses.

Employers with less than 20 employees
While the Certificates of Coverage will contain the new coordination of benefits language, UPMC Health Plan will start the implementation of the Medicare Secondary Payer rules on the group’s renewal date in 2021, starting with July 2021 renewals. For those groups that renew in first 6 months of 2022 (January-June), the Medicare Secondary Payer rules will take effect on their renewal date.

All size groups
For all other situations where Medicare is primary under the Medicare Secondary Payer rules, the effective date of the new provision in our Certificates of Coverage is the group's 2021 renewal date.

UPMC Health Plan will notify all impacted members via letter. Member Services will be ready to support impacted members through this transition.

If you have any additional questions, please contact your Small Market Account Manager or member services.