Employer Group Size Reporting

Under the MSP provisions, an employee is an individual who works for an employer, on a full or part-time basis, and receives remuneration for their work.  This includes anyone for whom a W-2 form was filed under the Employer Identification Number (EIN)/Federal Tax ID:

• including intermittent and/or seasonal employees.
• If the employer is part of a multi-employer/multiple employer plan, this field should reflect the size of the largest employer in the plan.
• Subsidiaries of foreign companies must count the number of employees in the organization worldwide.

Employer group size is determined by answering the following questions:

• Does an employer have less than 20 full and/or part-time employees for 20 or more weeks in the prior calendar year and are not part of a multi-employer group health plan?
• Does an employer have between 20-99 full and/or part-time employees for 20 or more weeks in the prior calendar year? The 20 weeks do not have to be consecutive.
• Does an employer have 100 or more full and/or part-time employees during the prior calendar year for 50% or more of the employer’s business days?

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) mandates reporting requirements with respect to Medicare beneficiaries who have coverage under a group health plan (GHP) as well as for Medicare beneficiaries who receive settlements, judgments, awards, or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation, collectively referred to as Non-Group Health Plan (NGHP) or NGHP insurance.

Section 111 reporting enables Medicare to correctly pay for the health insurance benefits of Medicare beneficiaries by determining primary versus secondary payer responsibility.

MSP is the term used by Medicare when Medicare is not responsible for paying first. MSP regulations for beneficiaries entitled to Medicare due to age or disability require information on employer size to determine the correct primary payer.¹ Employer size is based on the number of employees during specified time periods, not the number of individuals covered under the GHP.

¹ Employer size is not a factor if the beneficiary is entitled to Medicare due to ESRD.

As your insurer, HAP is required by law to report employer size data, quarterly, to the Centers for Medicare and Medicaid Services (CMS)² through Section 111 reporting. This reporting ensures proper coordination of benefit payments and protection of the Medicare Trust.

¹ Federal agency that oversees the Medicare program.

When calculating the number of employees, the GHP Responsible Reporting Entity (RRE) should use the total number of employees in an organizational structure rather than just the number of employees in the subsidiary being reported on.

The employer size indicator values reflect categories that are based on MSP regulations related to the number of employees during a specific period which affect whether Medicare is the secondary payer in conjunction with the reason an individual is entitled to Medicare (age and disability).