TN 23 (04-01)

A. BACKGROUND – MEDICARE SECONDARY PAYER PROVISION AMENDED

In 1986, the upper age limit of 69 was removed and Medicare became secondary payer for all those age 65 or over who were covered under a GHP of an employer of 20 or more employees, based on the current employment of an individual or his/her spouse of any age.

B. BACKGROUND – ENROLLMENT LIMITS AND PREMIUM SURCHARGE REVISED

1. Enrollment Limits

Congress also decided that the “working aged” who are covered under GHPs from employers of any size, based on their own or their spouse's current employment, will not be subject to the enrollment limitations or premium surcharge requirements for the period of time in which they have GHP coverage.

Thus, even though Medicare is secondary payer only when an individual is enrolled in a plan that covers 20 or more employees, an SEP and premium surcharge relief are possible for all those covered under a GHP of any size based on current employment.

A “catch up” SEP beginning 8/86 and a recalculation of the premium surcharge for premiums due beginning 6/86 was made available for everyone who met these new requirements but had not met the old rules.

2. Premium Surcharge Rollback

Effective for premiums due 6/86 and later, the calculation of the premium surcharge for late enrollment excluded:

• those months beginning with 1/83 (or age 65, if later) during which the individual was enrolled in a GHP based on his/her own or a spouse's current employment, even if the employer did not have 20 or more employees, and

• all months of SMI enrollment.