TN 25 (04-12)

HI 00805.266 Description of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions

A. Description of terms

The terms described in this section are those used with the special enrollment period (SEP) and premium surcharge rollback. They may or may not be the same terms used for Medicare as secondary payer. You must use the following description of terms to decide:

  • if an individual is eligible for the SEP,

  • when the SEP should begin, and

  • whether a premium surcharge rollback will apply and for what months.

TERM

DESCRIPTION

Group Health Plan (GHP)

The term GHP refers specifically to a group health plan based on the current employment status of the beneficiary or the beneficiary’s spouse. The GHP can be of any size, however when referring to a GHP for the disabled, the term refers to a plan of any size below 100 employees.

A GHP is any plan of, or contributed to by, one or more employers to provide health benefits or medical care (directly or otherwise) to current or former employees, the employer, or their families. The term GHP applies to the following types of plans:

  • self-insured plans,

  • plans of governmental entities (Federal, State, and local),

  • employee organizational plans (e.g., union plans or employee health and welfare funds),

  • employee pay-all plans (i.e., plans that are approved or sponsored by the employer or employee organization, but receives no financial contribution from them), and

  • national health plans in foreign countries.

The term does not include plans that are unavailable to employees; e.g., a plan that only covers self-employed individuals.

The employer does not have to be in the United States, and the employee is not required to be working in the United States. We consider a person working for a foreign employer who has a plan that meets the definition of GHP, to have coverage under a GHP for purposes of the SEP and premium-surcharge rollback. This also applies to individuals working in countries with national health plans.

Health Savings Account

Health Savings Accounts (HSAs) are NOT group health plans. They are tax-exempt trusts or custodial accounts that are set up with a qualified HSA trustee to pay or reimburse certain medical expenses.   To be an eligible individual and qualify for an HSA, the individual must be covered under a high deductible health plan (HDHP) and not entitled to Medicare Part A. To be eligible for the SEP for the working aged or working disabled, the individual must have coverage under a HDHP based on current employment.

Current Employment Status

A. An individual has “current employment status” if he or she is actively working as an employee, is the employer (including a self-employed individual), or is associated with the employer in a business relationship.

An individual also has “current employment status” if he or she is not actively working, but meets all of the following conditions:

  • retains employment rights in the industry;

  • the employer has not terminated the individual’s employment or the employee organization providing the coverage has not terminated the individual’s membership in the employee organization;

  • is not receiving disability benefits from an employer for more than 6 months;

  • is not receiving Social Security disability benefits; and

  • has employment-based GHP coverage that is not COBRA continuation coverage.

Persons who retain employment rights include, but are not limited to:

  • those who are on strike, furloughed, temporarily laid off, or who are on sick leave;

  • teachers and seasonal workers who normally do not work throughout the year; and

  • individuals age 65 and older who have health coverage that extends beyond or between periods of active employment; for example, based on an hours’ bank arrangement.

Active union members in certain trades and industries (e.g., construction) often have “hours’ bank” coverage.

For SEP Enrollments for hours’ bank arrangements see HI 00805.278.

B. The following information defines “current employment status” for specific situations:

  1. Individual covered under a retirement GHP is rehired

A group health plan based on former employment becomes a GHP based on “current employment status” if the:

  • employer who is furnishing the retirement GHP rehires the individual, and

  • amount of work the individual performs is sufficient to earn coverage from the employer had the individual not retired.

The individual who meets the requirements in this section has GHP coverage based on current employment status. This is true even if the employer deducts payment for the GHP coverage from a pension or annuity payment.

If employed by an employer other than the one providing the group health plan coverage the GHP is a retirement plan and the employee does not have GHP coverage based on current employment status.

2. Employment Status of Senior Judges

Senior Federal judges are retired judges of the U.S. court system or the Tax Court. They may continue to adjudicate cases, but they are entitled to full salary as a retirement benefit whether or not they perform judicial services for the government. The remuneration they receive as senior judges are not wages and do not count as earnings for Social Security retirement test purposes.

Since senior judges are considered retired for Social Security purposes, they are not considered to have current employment status for purposes of the SEP and premium-surcharge rollback.

3. Clergy and members of religious orders

We consider members of religious orders who have not taken a vow of poverty to have current employment status with the order if the:

  • religious order pays FICA taxes on behalf of that member; or

  • individual receives remuneration from the order for services furnished, regardless of whether the order pays FICA taxes on behalf of that member.

We do not consider members of religious orders who have taken a vow of poverty to have current employment status if the services performed as a member of the order are considered employment for Social Security purposes only because the order elected Social Security coverage under 3121(r) of the Internal Revenue Code.

4. Individuals serving as volunteers

 

Volunteers have current employment status if they perform services or are available to perform services for an employer and receive payment for their services.

For example, we consider AmeriCorps (which includes VISTA, the National Civilian Community Corps, State and National volunteers) and Peace Corp volunteers to have current employment status since they receive remuneration from the Federal Government.

Payment may be monetary or non-monetary. We consider benefits (including health benefits) that a volunteer receives as payment if the benefits are subject to FICA taxes under the Internal Revenue Code.

5. Directors of Corporations

Directors of corporations (i.e., persons serving on a Board of Directors of a corporation who are not officers of the corporation) are self-employed.

Directors who receive remuneration for serving on a board to have current employment status. Remuneration may be of a monetary or nonmonetary nature. Benefits, including health benefits that a corporation provides to a board member, are remuneration if they are subject to FICA taxes under the IRC.

See also:

HI 00805.290 SEP Requirements for Self Employed Individuals

Large Group Health Plan (LGHP)

The term "LGHP" refers exclusively to disabled beneficiaries who are under age 65.

An LGHP is a group health plan that is available to employees of one or more employers who normally employed at least 100 employees on at least 50 percent of its business days during the previous calendar year.

If a plan is a multi-employer plan, such as a union plan that covers employees of some small employers and employees of at least one employer that meets the 100 or more employees’ requirement, Medicare is the secondary payer for all employees enrolled in the plan. In this situation, we consider all the employers (large and small) in the multi-employer plan "large," and their plan coverage is LGHP coverage.

LGHP Is No Longer a Large Plan

An LGHP is no longer considered a large plan effective January 1 of the year following the year in which the employer no longer employed 100 employees on at least 50 percent of its business days in that year. For purposes of these instructions, treat it as a GHP at that point. The CMS Regional Office should resolve any questions about the size of a plan.

Medicare Secondary Payer (MSP) Provisions

Medicare is secondary payer for services covered under any of the following:

Group health plans of employers that employ at least 20 employees and that cover Medicare beneficiaries age 65 or older who have coverage under the plan by virtue of the individual’s current employment status with an employer or the current employment status of a spouse of any age.

Large group health plans of employers that employ 100 or more employees and that cover Medicare beneficiaries who are under age 65, entitled to Medicare on the basis of disability, and covered under the plan by virtue of the individual’s or a family member’s current employment status with an employer.

Medicare is secondary for these individuals even if the employer policy or plan contains a provision stating that its benefits are secondary to Medicare benefits or otherwise excludes or limits its payments to Medicare beneficiaries.

See also:

  • HI 00620.177 Medicare as Secondary Payer for End Stage Renal Disease (ESRD) Beneficiaries and for Employed Beneficiaries Age 65 or Over (Working Aged) and the Spouses Age 65 or Over of Employed Individuals of Any Age

  • HI 00620.178 Medicare as Secondary Payer for Disabled Individuals

Disabled Medicare Beneficiary

A "disabled Medicare beneficiary" is a disabled worker, a disabled widow(er), or a disabled adult child who is under age 65 and is entitled to Medicare because of his or her disability, except those who have end-stage renal disease (ESRD).

NOTE: There is no SEP or premium-surcharge rollback for those who have ESRD.

For instructions on possibly delaying Medicare enrollment based on ESRD, see HI 00801.191D.3.

Spouse

We consider an individual to be a spouse for SEP purposed if he or she is a:

  • spouse for Title II purposes (see RS 00202.001); or

  • divorced spouse.

If a former spouse’s GHP or LGHP covers a divorced spouse, we consider the divorced spouse to be a “spouse” for purposes of these provisions even though he or she may not meet the Title II definition.

Family Member

A family member is “a person enrolled in an LGHP based on another person’s enrollment.”

The term includes individuals who are:

  • related (by blood, marriage, or adoption), and

  • not related, provided they are enrolled in the LGHP based on the worker’s enrollment.

Family members include, but are not limited to a:

  • spouse;

  • natural, adopted, foster, or step-child;

  • parent; or

  • sibling.

Domestic (or life) partner –We consider a domestic partner who is under age 65, entitled to Medicare based on disability and has coverage under an LGHP based on the other partner’s enrollment in the plan to be a family member for the purposes of these provisions.

B. References

RS 02505.015 When Employment Relationship (ERS) Terminates

HI 00805.290 SEP Requirements for Self-employed Individuals


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HI 00805.266 - Description of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions - 09/17/2013
Batch run: 09/17/2013
Rev:09/17/2013