Medicare Secondary Payer Change Form
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27001 220th St. SW, MS 266
Medicare Secondary Payer Change Form
Mountlake Terrace, WA 98043-2124
Important information to assist your group in complying with the Medicare Secondary Payer (“MSP”) laws.
See the back of this sheet for relevant MSP definitions. Refer to the Medicare Secondary Payer Overview for information on the purpose of this form.
If you answer “No” to questions 2, 3 and 4 below you do not need to submit this form.
GROUP INFORMATION
A. Group Name _______________________________________________________________________________________
1.
B. Group ID __________________________________________________________________________________________
C. Address ___________________________________________________________________________________________
D. City, State, ZIP ______________________________________________________________________________________
E. Contact Person Name ________________________________________________________________________________
F.
Contact Person Phone ________________________________________________________________________________
G. Are you part of a Multiple Employer Group Health Plan?
q Yes
q No
q Yes
q No
2.
Since submission of your last Group Master Application, are you reporting a change in group size?
If no, skip to section 3.
q Yes
q No
A. My group had less than 20 employees under MSP rules and now has 20 or more employees under MSP rules.
q Yes
q No
B. My group had 20 or more employees under MSP rules and now has less than 20 employees under MSP rules.
q Yes
q No
C. My group had less than 100 employees under MSP rules and now has 100 or more employees under MSP rules
q Yes
q No
D. My group had 100 or more employees under MSP rules and now has less than 100 employees under MSP rules.
E. If you answered yes to any of the above, complete the following:
•
Total employee count reported previously
•
Current total employee count
•
Effective date of change in employee count
3.
Since submission of your last Group Master Application, are you reporting changes to employee work status for any of your
q Yes
q No
Medicare-eligible employees?
If the answer is “yes”, please complete the following:
Change of Enrollee Work Status:
Enrollee Name (Last, First, Middle Initial):
Enrollee Social Security Number:
q Current Employment
q Retired as of:
q Disabled as of:
q COBRA as of:
Prior Enrollee Status:
(check one)
Status:
(see back for definition)
q Current Employment
q Terminated as of:
q Retired as of:
q Disabled as of:
q COBRA as of:
New Enrollee Status:
(check one)
Status:
(see back for definition)
4. Since submission of your last Group Master Application, do you have additional
q Yes
q No
Medicare-eligible employees?
If the answer is “yes”, please complete the following:
Enrollee Name (Last, First, Middle Initial):
Enrollee Social Security Number:
q Current Employment
q Retired as of:
q Disabled as of:
q COBRA as of:
Enrollee Status:
(check one)
Status:
(see back for definition)
I certify that the information provided above is true. If there is a change to this status, I understand that it is the group health plan’s responsibility to
advise LifeWise Health Plan of Oregon promptly of the change.
Print Name: _______________________________________________________________ Title: ________________________________________
Signature of Group Health Plan Representative: ___________________________________ Date Signed: _________________________________
(See Next Page for Medicare Secondary Payer Definitions)
019361 (08-2008)
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