Medicare Secondary Payer - Small Employer Exception

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19 East 34
Street
New York, NY 10016
(212) 592-1800
(800) 223-6602
Medicare Secondary Payer – Small Employer Exception
Employer Name: ____________________________________________________________________
Address: ___________________________City: _____________________ State: _____ Zip: _______
Employer’s 9-digit Employer Identification Number (EIN): ________________________________
Check one box below to indicate whether or not the employer wants to apply for and participate in the
MSP Small Employer Exception.
Yes—Employer elects to participate in the MSP Small Employer Exception and certifies that it has
☐
had 19 or fewer employees for each working day in each of 20 or more calendar weeks in the current
and preceding year. This means the employer is exempt from the MSP rules and Medicare will become
the primary payer of Medicare Part A claims for individuals meeting the guidelines as stated.
No - Employer elects not to participate in the MSP Small Employer Exception.
☐
If no, enter the current number of employees for your organization
______________
(Include all full- and part-time employees who have worked or are anticipated to work at least 20 calendar
weeks of the year. Consider any employee who receives a W-2 under this EIN and self-employed clergy.)
Then please sign, date, and return the form. Thank you.
Certification and Signature
We hereby certify that this information is true and accurate as of the date of this certification. We agree
to notify the Medical Trust if our employee count changes in the future from fewer than 20 employees
to 20 or more, or from 20 or more employees to fewer than 20.
If we have elected to participate in the MSP Small Employer Exception, we understand that this means
that Medicare Part A would become the primary insurance for the eligible active employees age 65 or
older, and/or their spouses age 65 or older. We certify that each individual for whom we are providing
an Employer Election Form has coverage because he/she is currently an active employee or the spouse of
an active employee.
Authorized Employer Representative
Date
Group Benefits Administrator
Date
Please mail or fax the completed form to:
By Fax:
By Mail:
Episcopal Church Medical Trust
212-592-9408
Bob Griffith, MSP Small Employer Exception
Bob Griffith, MSP Small Employer Exception
19 East 34th Street
New York, NY 10016
Please note that this document is provided for informational purposes only and should not be viewed as
legal, tax or other advice. Please consult with your own professional advisor for further guidance.

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