US · guidance
CMS Pub. 100-16, ch. mc86c17b, § 340
Benefit Coordination for Working Aged Individuals Entitled to
Medicare
(Rev. 4, 10-01-01)
Under §1862(b)(1)(A) of the Act, if an employer has 20 or more employees (calculated
as described below) and offers a group health plan (referred to here as an EGHP), the
EGHP is the primary payer for individuals who are 65 or over, and who are covered
under the plan based on current employment of the individual or the individual’s spouse.
(Medicare remains the primary payer for retirees.)
Medicare is secondary only if the individual is entitled to Medicare Part A. Generally,
Medicare is not secondary for persons over age 65 who have ESRD. The law also
prohibits EGHPs from taking into account, in furnishing services, that an individual is
entitled to Medicare benefits, and requires that employees or their spouses, who are 65 or
over, be entitled to the same benefits under the same conditions as individuals under age
65. If the EGHP violates either of these provisions, Medicare is entitled to collect primary
payments from the organization as if the violations had not occurred. The nonconforming
plan is also subject to an excise tax imposed under the Internal Revenue Code (IRC).
History
(Rev. 4, 10-01-01)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
de7ea70cbd5f5d9073c07ec98bb6f4469b1faca28e1b6a3dcbbf63fad921b1bb
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