HomeMy WebLinkAboutWellmark-5/4/2015 (8)Wellmark®
An Independent Licensee of the Blue Cross and
Blue Shield Association
Clear Form's
FOR ADMINISTRATIVE USE ONLY
New Group: Group #
Coverage Effective Date:
CONFIRMATION OF MSP ADDENDUM
ALL NEW AND RENEWAL GROUPS ARE REQUIRED TO SUBMIT A COMPLETED FORM. FAILURE TO SUBMIT A COMPLETED
FORM WILL DELAY THE INITIAL ENROLLMENT OR RENEWAL PROCESS
UNTIL THIS FORM IS SUBMITTED.
Part A - Employer Information
Please complete a separate confirmation form for each Employer Tax Identification Number you use to report employee
earnings to the Internal Revenue Service (IRS). See the Medicare Secondary Payer Definitions page (M-1756) for more
information on terms shown in italics.
Employer Tax Identification Number: Ei 6E 0� 0� Ei E1
Group Number (Renewing Groups Only): XA025
Employer Name: City of Waterloo
Employer Address: 715 Mulberry St
City: Waterloo
Contact Person: S u-44 Scharf 5
State: IA Zip: 50703
Telephone Number: 3I q . -cl I . L1522. £' T' 3oog E-mail Address (optional): SU2L se iarec C I L'lerttb— 0.A4
1. Did your organization make contributions on behalf of any employee who was covered under a
collectively bargained Health and Welfare Fund (i.e., union plan) during the previous calendar year?
2. Did you have 20 or more employees for 20 or more calendar weeks (this includes all full-time, part-time,
intermittent, leased and/or seasonal employees, not just those eligible or enrolled employees) during the
previous or current calendar year? If no, in the event you experience a change, you must notify Wellmark
when this change occurs.
3. Did you have 100 or more employees during 50 percent of your business days (this includes all full-time,
part-time, intermittent, leased and/or seasonal employees, not just those eligible or enrolled employees)
during the previous calendar year?
4. Did your organization participate in a multi or multiple employer group health plan (more than one
employer in group, i.e., Multiple Employer Welfare Association) during the previous calendar year?
If yes, what is the name and address of the multi or multiple employer plan?
Name:
Address:
City: State: Zip:
5. Was your organization part of a commonly owned or commonly controlled group of organizations during
the previous calendar year?
If yes, what is the name and address of the commonly owned/controlled entity?
Name: Name:
Address: Address:
City: State: Zip: City: State: Zip:
Part B - Employer Certification
I certify that the information provided is accurate and truthful. All information will be used to identify the
lyledicare Seco ayer status of Medicare -enrolled employees.
❑ Yes afclo
(j'Yes ❑ No
[Iles ❑ No
❑ Yeso
❑ Yes PIo
Signature
Date
Send completed V1SP form based on following:
IA & SD Large Groups (new or
renewal)
IA & SD Small Groups (new or
renewing with benefit changes)
IA Small Groups renewing with no
benefit change - send this form to:
SD Small Groups renewing with no
benefit change
Submit this completed MSP
form with group's health plan
new or renewal paperwork
Submit this completed MSP form
with group's health plan new or
renewal paperwork
Fax: (515) 376-9044 or
Wellmark, Inc.
PO Box 9232 — Mail Station 3W396
Des Moines, IA 50306-9232
Send this completed MSP form to:
Wellmark, Inc.
PO Box 5023 — Station 338
Sioux Falls, SD 57117-5023
N-2305 12/10
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Wellmark.
An Independent Licensee of the Blue Cross and
Blue Shield Association
MEDICARE COMPLIANCE
The purpose of this communication is to notify employers of the mandatory reporting requirements of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 which were passed into law in July 2008. Your cooperation in providing
the necessary employer data and data for each employee and dependent is needed in order to comply with the
requirements.
The Section 111 mandates of the law help payers identify when the Centers for Medicare and Medicaid Services (CMS)
should pay secondary to employer group health coverage. The goal includes reducing the amount CMS may pay as
primary when they should have paid as secondary.
Under the requirements, all health plan, liability, no fault and workers compensation coverages must register with CMS
as a Responsible Reporting Entity (RRE) and must report to CMS employer and member information. In order to fulfill
the mandated requirements and report accurately to CMS, Wellmark, as a RRE, must gather and groups must provide
the following information:
O Employer Tax Identification Number (ETIN)
O Evidence of status as a Commonly Owned/Controlled Group of Organizations, Multi/Multiple Employer
Group health plan (such as an Association or Trust), Hour Bank or Union health plan
O Total number of group employees/group size
O Social Security Numbers (SSNs) or Health Insurance Claim Numbers (HICNs) of active employees,
spouses, domestic partners
® SSNs or HICNs for those dependents with end stage renal disease (ESRD) or disabled
® Status of all employees and effective date of that status (Le. active, COBRA, retired)
® Disability information begin or end dates, if known
Please take a moment to complete the Confirmation of Medicare Secondary Payer (MSP) Addendum form. This will
allow us to capture your employer data for reporting to CMS. Member data is gathered through the use of the group's
existing enrollment and eligibility data collection channels, which may include paper applications or electronic data
exchanges and should be provided through those processes.
Failure to provide the group information requested on the attached Confirmation of MSP Addendum can result in
penalties being assessed to the group including, but not limited to, $1,000 per day per member for not accurately
reporting to CMS and/or an excise tax equivalent to 25 percent of the employer's group health plan expenses for the
relevant year.
Wellmark Blue Cross and Blue Shield of Iowa I 1331 Grand Avenue I PO Box 9232 I Des Moines, Iowa 50306-9232 I wellmark.com
N-2305 12110
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