CMS Pub. 100-16, ch. mc86c18b, § 190.1

Under §1862 (b)(1)(B) of the Act, Medicare is secondary payer to LGHPs for active

individuals under age 65 entitled to Medicare on the basis of disability. Under the law,

an LGHP may not take into account that an active individual is eligible for or receives

benefits based on disability. The individual's coverage under the LGHP must be based on

the individual's employment or the employment of a family member. Refer to §3492 of

the Medicare Intermediary Manual for processing claims where Medicare is secondary

payer for disabled individuals. Where those sections refer to an EGHP of 20 or more

employees, substitute the term "large group health plan" for purposes of applying them to

disabled individuals. This provision is effective for items and services furnished on or

after January l, 1987, and before October 1, 1995.

A large group health plan means any health plan that meets the following criteria:

• Is paid for by or contributed to by an employer or by an employee organization,

including a self-insured plan;

• Provides health care directly or through other methods such as insurance or

reimbursement to employees, the employer, other associated or formerly

associated with the employer in a business relationship or their families; and

• Covers employees of at least one employer that normally employed at least 100

full or part-time employees on a typical business day during the previous calendar

year. The term "employer," for the purpose of this provision, includes the Federal

government and other governmental entities.

A group health plan that covers employees of at least one employer that had l00 or more

employees on 50 percent or more of its business days during the preceding calendar year

is considered to meet the above definition of an LGHP.