US · guidance
CMS Pub. 100-16, ch. 8, § 70.4
Adjustment of Monthly Payments for Medicare Secondary
Payment Status
(Rev. 89; Issued: 11-02-07; Effective/Implementation: 11-02-07)
70.4.1 – Working Aged Adjustment
(Rev. 112, Issued:05-10-13, Effective:10-01-13, Implementation: 10-07-12-Coding Changes to create the new field in the CWF feed to MBD will be made in October; January 6, 2014- The utility and cleanup will he completed as part of the January
release)
CMS makes a payment adjustment for managed care enrollees who are working aged or
disabled and covered under another’s employment insurance. Beneficiaries are “working
aged” if they are aged 65 or older, currently working for an employer with 20 or more
employees, and have health insurance coverage through the employer’s group health plan.
Medicare-eligible spouses who are aged 65 or older, with health insurance coverage under
a currently employed spouse’s employer group health plan (if that employer has 20 or more
employees) are also assigned working aged status (even if the currently employed spouse is
under 65 years of age and not yet entitled to Medicare). Disabled beneficiaries covered
under other employment insurance benefits will only appear as “disabled” in MSP files.
Medicare spending for these beneficiaries is significantly lower than spending for other
beneficiaries because other insurers are primary to Medicare. In 1995, working aged status
was added as a factor for adjusting payments to managed care organizations with §1876
risk contracts. However, in 2010, CMS started reducing payments for MSP on a
beneficiary instead of contract basis. MSP information received from insurance companies,
the beneficiaries themselves, and managed care plans are used to adjust individual
beneficiary payment amounts.
CMS sends plans monthly reports that include all of the beneficiaries where Medicare is
the Secondary Payer. These reports are explained in depth in the Plan Communications
User Guide. If plans disagree with CMS’ determination that their enrollees have other
employer insurance coverage, they can submit a correction via ECRs as described in the
IOM, Chapter 5.1 of Publication 100-05 Medicare Secondary Payer Manual.
History
(Rev. 89; Issued: 11-02-07; Effective/Implementation: 11-02-07)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
6142beb18095a15617806d0fa18b0b6d46cb90b449e5192c5177c9195f0eda01
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