~~~~~~ ~~~~~
,..
Deparment of. Health and Human Services

OFFICE 
INSPECTOR GENERAL

EXTENT OF UNRECOVERED MEDICARE

SECONDARY PAYER FUNDS

" "ov

J!L 
AUGUST 1991 
t4-Yd:lO  OFFICE OF INSPECTOR GENERAL

The mission of the Offce of Inspector Genera (OIG), as mandated by Public Law 95-
452, as 
amended, is to protect the integrty of the Depanment of Health and Human Services ' (HS)
programs as well as the health and welfare of beneficiares served by those progrs. 
This 
statutory mission is cared out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components: the Office of Audit Services, the 
Office of Investigations, and the Offce of Evaluation and Inspections. The OIG also informs the 
Secretary of HHS of program and management problems and recommends courses to correct 
them. 
OFFICE OF AUDIT SERVICES 
The OIG' s Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
caring 
out their respective responsibilities and ar intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and effciency throughout the Deparent 
OFFICE OF INVESTIGATIONS 
The OIG' s Office of Investigations (01) conducts crminal, civil, and admnistrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiares and of 
unjust enrichment by providers. The investigative efforts of 01 lead to crminal convictions, 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecUte frud and patient abuse in the Medicaid program. 
OFFICE OF EVALUATION AND INSPECTIONS 
The OIG' s Offce of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Deparent, 
the 
Congress, and the public. The findings and recommendations contaned in these inspection 
reports generate rapid, accurate, and up-to-date information on the effciency, vulnerability, and 
effectiveness of depanmental programs. 
This report was prepared in the Kansas City Regional Offce under the direction of Don 
McLaughlin, Regional Inspector General, and James H. Wolf, Deputy Regional Inspector 
General. Project Staff: 
Project Leader  Tom Noplock Headquarters 
Hugh Owens, 

Bar 
Doris Phillips  Headquarters 
Steeley, 
Julie Quirin  Headquarters
Mark Krshat, 

Perry Seaton  Linda Moscow Headquarters  ;. 

:::
Department of Health and Human Services 
OFFICE 
INSPECTOR GENERAL

EXTENT OF UNRECOVERED MEDICARE

SECONDARY PAYER FUNDS

tRVICES' 
Richard P. Kusserow 
INSPECTOR GENERAL 
'0 
OEI-07-90-00760 
lt  4-Yd:lO  - p
-"'. ---
EXECUTIVE  SUMMARY

PURPOSE 
To determine the extent of the unrecovered funds related to Medcar seconda payer (MSP) 
progr 
provisions and to identify varous options to prevent Medicare  losses due to 
unidentified primary insurance sources. This report finalizes preliminar findings and 
recommendations made in a management advisory report (OEI-07-90-00764) issued in June 
1990. 
BACKGROUND 
certn 
Congress passed a series of statutory provisions between 1980 and 1986, which made 
priar 
other insurers primar to Medicar. These insurers became  for beneficiares insured by 
employer group health plans (EGHPs), automobile medical, no-fault, and liabilty insurance as 
well as for end-stage renal disease. 
This inspection relates to the Secreta s goal of enhancing the effectiveness of Medicar 
reimbursement through assuring that Medicar reimbursement is seconda to other insurance. 
METHODOLOGY 
We selected a sample of all beneficiares who received services in 1987. We contacted a 
sub-sample of this group about their medical insurce coverage and about any accidents in 
which they may have been involved. Almost 73 percent of the beneficiares responded. 
FINDINGS 
Although the Health Care Financing Administration (HCFA) has made extensive efforts to 
identify MSP situations, we found significant overpayments totaling over $637 million in 
1988. 
We identified overpayments of $60,502 in our sample which projects to a loss of over $637 
milion in 1988 to the Medicare program. 
Targeting working spouses and disabled can increase the cost effectiveness of MSP efforts. 
The overall cost to benefit ratio in this study was 5.4 to 1. However, the cost-benefit ratio for 
developing spousal insurance cases was 10.2 to 1 and the cost-benefit ratio for developing 
disability cases was 11.
0 to 1.  -_.
.-.------------- --
RECOMMENDATIONS 
progr 
The HCFA should take action to prevent Medicare  losses due to unidentified primar 
ar: 
insurers. This can be accomplished in a varety of ways. Among them 
Revise all Medicare cla m forms to require spousal insurance information before claims 
can be paid. 
Proritize the information received from IRS and SSA according to those areas with the 
greatest cost-benefit ratio. 
Propose legislation to establish a Voluntar Disclosure and Recovery Program. 
priar 
Establish a national data system containing  insurance information on all Medicare 
beneficiares and their spouses. 
Propose legislation to require Medicare contractors to match their private health insurnce 
records with Medicare fies. 
Propose legislation to require all insurers to provide their private health insurance data, 
payment information, to HCFA. 
including eligibilty and claims 
Recommend to Congress that section 6202 of Public Law 101-239 (as amended by Public 
Law 101-508) be extended beyond the statute s termnation date of September 30, 1995 
until legislation is enacted requiring diect employer reportng. 
COMMENTS 
AGENCY 
The HCFA commented on an earlier version of this report. They were general y in agrement 
with the recommendations, except for the matching of contrctor private health insurance 
importt 
We continue to believe that the matching of records is an 
records with Medicare fies. 
fiduciar responsibility of Medicare contractors who should reference all sources of information 
to identify primar payer sources.  ............................................................................................................................................... ..................  .............................. .......................-...... ..-.. .  ._..........-.............. .....-.... ..-......-. .....-.......-........ .........-................  ..... ..................................... ............ .. ............ .............. .. .......................... ............................................. ...................... . .............. ..................................... .................................. .......... .. ......................
TABLE OF CONTENTS

EXECUTIVE SUMMARY 
INTRODUCTION.................................................................................. ....................

PURPOSE.................................... .................. 

BA CK G ROUND................................ ...................... ..........................................

METH 0 DO LOG Y.................... ............ 

FIND IN G S .................................................................................................................. 3 
RECO MMEND A TIO NS .. .............. ...... ...... 
A G EN CY COMMENTS.. 
APPENDIX A .......................................... .............. ...................... .............. .......... .. A
APPENDIX B 
APPENDIX C  ............................................. C
APPENDIX D  ................................ D
APPENDIX E 
_n_  INTRODUCTION

PURPOSE 
To determine the extent of the unrecovered funds related to Medcar seconda payer (MSP) 
provisions and the varous options available to the Health Care Financing Admnistrtion 
(HCFA) to prevent losses to the Medicar program due to unidentified primar insurance 
sources. This report finalizes preliminar findings and recommendations made in a maagement 
advisory report (OEI-07-90-00764) released to HCFA in June 1990. 
BACKGROUND 
Title XVIII of the Social Security Act (42 USC 1395), enacte in 1965, established the Medicare 
program to pay for health care services for eligible beneficiares age 65 and older. Also, 
beneficiares are covered who were disabled and those with end-stage renal disease (ESRD). 
Until 1980, Medicare was primar payer for all health care costs (less co-pay and deductibles) 
for these beneficiares. Concurrent coverage by other payers was considered seconda. The 
only exceptions to this rule were services covered by workers' compensation and services by 
other Federal programs, such as the Veterans Administration. 
progr 
Growing concern for rising Medicare  costs influenced Congrss to pass a series of 
statutory provisions durig the period betWeen 1980 and 1986. (See Appendix A.) These 
provisions require certain private insurers to pay medcal claims before Medcare if the aged or 
disabled beneficiar has other health insurce coverage by an employer group health plan 
(EGHP) or by the spouse s EGHP. Medicar is also secondar payer if the beneficiar has an 
accident and is covered by automobile medical, no-fault, or liabilty insurance. Another 
statutory provision made Medicare the secondar payer for items and services furnished to 
ESRD beneficiares who are covered under EGHPs during a specified period of up to 12 months. 
In general, providers are required to bil other insurers first when a beneficiar falls within one 
of these categories. Medicare pays any remaining amounts for which it may be responsible. 
The HCFA is responsible for ensuring contractors comply with Medicare legislation and 
regulations. Further, HCFA provides contracto s with procedures and instrctions concerning 
the identification of MSP situations and recovery of inappropriate payments. As pan of their 
fiduciary responsibilty, contractors should identify and record information for beneficiares 
having primar medical insurance coverage. 
Medicare contractors were budgeted approximately $115 millon for administration of MSP 
provisions in the law during Fiscal Years (FYs) 1987 and 1988. The data from HCFA shows 
MSP savings to be $3.3 bilion ($1.1 bilion for Pan A and $.3 bilion for Pan B for FY 1987 and 
$1.4 bilion for Pan A and $.5 bilion for Pan B in FY 1988). However, diffculties in de!ecting .  primar payment sources stil exist which result in substantial losses to Medicare. Despite 
current procedures for HCFA's educational and outreach programs, Offce of Inspector General 
(OIG) inspections and audits, Genera Accounting Offce (GAO) audits, and HCFA pilot studies 
ar 
have confirmed that additional savings and recoveries  possible. These prior inspections and 
studies claim estimates of progrm losses raging from $300 million to $900 millon each year. 
Recently, congrssional hearngs, GAO audits, and media attention have focused on report of 
unrealized savings. In addition, lawsuits under Qui Tam provisions of the False Claims Act and 
Deparent of Justice actions have brought the MSP issue to the forefront. 
METHODOLOGY 
We selected a simple random sample from al beneficiares who received services in 1987, which 
00 
resulted in identifying over 350, beneficiares. Next, we took a sub-sample of this group, 
the 
using sequential sampling, which identified over 6,700 beneficiares. We deleted 
categories in the sub-sample: Railroad Retirement beneficiares, dece sed beneficiares, and 
those beneficiares with non-matching Health Insurace claim numbers. These groups were 
dropped because suffcient data was not available to include them in our sample. 
After the categories mentioned above were dropped, this left over 4 300 beneficiares in our 
sub-sample. We attempted to contact the beneficiares about their medical insurace coverage 
and any accidents in which they may have been involved. Almost 73 percent of the beneficiares 
responded. More detailed information on the sample selection process is given in the surey 
methodology section of Appendix B.  FINDINGS

The following findings are based on an analysis of the 34 conflIed overpayment cases. Each 
case may be included in one or more of the analysis categories. These categories are not 
mutually exclusive. 
Although RCF A has made extensive efforts to identify MSP situations, we found 
signifcant  milion in 1988. 
overpayments totaling over  $637 
Our total overpayment projects to an estimated loss to the Medicar program of over $637 
prima 
million in Calendar Year 1988. (See Appendix B.) The completed analysis identified 
insurance coverage on 34 beneficiares (33 EGHP and 1 accident) out of the 3, 185 beneficiares 
or about 1 percent of those who responded. (See Appendix C.) We identified $4 744 paid by 
par 
Medicare in the accident liabilty case for which a third- payer had responsibilty for 
represents 8 percent of the tota overpayment identified. We established 
payment. This amount 
progr 
an actual loss to the Medicare  of $60,502, of which Pan A payments totaed $29,695 
and Pan B $30,807. 
We found that over $583.3 millon of the projected loss to the Medcar program was due to 
unidentified spousal insurance coverage. Twenty-five of the 33 beneficiares (76 percent) with 
EGHP coverage had unidentified primar insurance coverage through their working spouses. 
Of the $60,502 identified, a total of $54 294 
Included in the 25 cases were eight disabilty cases. 
was due to this coverage. This was alost 90 percent of the tota identified overpayments. 
We project an annual loss for unidentifed disabled beneficiares of over $265 milion.

Nine of the 33 beneficiares (27 percent) with an EGHP received Medicar coverage because of

a disabling condition and accounted for over 47 percent or $28,393 of the total overpayment.

Eight of the disabled beneficiares were insured through their spouses ' EGHP and one

beneficiar through his own EGHP.

We project an annual loss of almost $16.5 millon for unidentified coverage of the workig 
EGHP coverage 
beneficiar. Seven of these 33 beneficiares (21 percent) had unidentified 
through their own employer. This includes one disabled beneficiar. These working 
beneficiares accounted for 2 percent or $1,449 of the total overpayment. 
We found that Medicare contractors are not coordinating with their private insurance operations. 
Medicare paid as the primar payer in eight cases when the beneficiar had primar payer 
coverage through an EGHP administered by the contractor s private business operation. Three 
that there was other insurance. The other five 
of the cases had identifying information in the fie 
cases did not have other insurance information in the file because the claims were submitted 
electronically.  OVERPAYMENTS 
by Case Category 
Working Spouses

90% 
Accident 
Wkg Beneficiaries 
Calendar Year 1988

Targeting working spouses and disabled can increase the cost effectiveness of MSP 
efforts. 
We identified administrative costs accrued by the OIG to detect and develop unidentified
priar  progr 
When compared to the  loss, 
insurance coverage for the sampled beneficiares. 
prima 
based upon identified  insurance coverage, the overall cost to benefit ratio was 5.4 to 1. 
However, the cost effectiveness of developing insurance information for those respondents who 
insurce 
reported that their spouse was insured increased to 10.2 to 1. The development of 
information concerning disabled individuals had an even higher cost to benefit ratio of 11.0 to 
(See Appendix D.) The increased ratio equates to a higher overpayment identified for the 
spousal and disability cases.  RECOMMENDATIONS

The HCFA should take action to prevent Medicare program losses due to unidntified primary 
insurers. This can be accomplished in a variety of ways. Among them are: 
Revise all Medicare claims forms to require spousal insurance information before 
claims can be paid. 
We suggest that the following information be obtained as pan of the application: 
Is the beneficiar covered by an EGHP though his or her own employer or the em
ployer of the spouse? 
If yes, enter the name and Social Security number of the person working, the name of 
the employer, and name of the insurance company. 
Prioritize the information received from IRS and SSA according to those areas with the 
greatest cost-benefit rati. 
Section 6202(a) of OBRA of 1989 (Public Law 101-239) established a systematic process 
wil fursh 
of providig MSP information to HCFA. The Act provides that the IRS  spou
sal information on any Medicare beneficiares identified by SSA. The SSA wil furish 
wage information on Medicar beneficiares and their spouses to HCFA. 
The cost-benefit ratio of developing cases involving the working spouse covere by an 
EGHP is considerably more than for working beneficiares covered by an EGHP. This 
provides justification that initial efforts should develop those cases with indications of a 
working spouse. In our sample, 25 out of 33 EGHP overpayment cases involved working 
spouses, which produced our largest porton of the overpayment. . 
Propose legislation to establish a Voluntary Disclosure and Recovery Program. 
par 
The program would permit insurers, employers, or third- administrators, acting 
within one year of enactment, to identify instances of improper MSP payments and make 
restitution of the appropriate amounts without theat of future Government action with re
spect to those claims. The legislation should also provide for a waiver of the existing stat
ute of limitations applicable to improper MSP payments. Any insurer norpartdpating in 
this program would be subjecLto a civil penalty of treble damages, plus costs, with respect 
to all improper MSP claims later identified by the government  Establish a national dam system conmining primary insurance information on all 
Medicare beneficiaries and their spouses. 
The HCFA should continue to pursue legislation requirng the insurer, underwters, and

third pany admnistrtors of health plans to notify HCFA about covered individuals who

are age 65 and over, under age 65 and disabled, or diagnosed as having ESRD, and who

are enrolled in insurance progrs to which Medcare is seconda payer.

Alternatively, this could be embodied into a broader proposal to establish a national clear
inghouse of information pertaining to medical insurace available to beneficiares of al 
Federal and State health benefit programs. Under this proposal HCFA would run claims 
through this clearnghouse in order to identify MSP situations. 
Propose legislation to require Medicare contractors to match their private health 
insurance records with Medicare files. 
The HCFA contracts with health insurance companies to adjudicate and pay Medicar 
claims. In this capacity, Medicar contrctors have a fiduciar responsibilty to the Fed
eral government to assure that only appropriate Medicar payments ar made. If contrac
tors were required to match primar beneficiares to their private business, all such cases 
in this inspection should have been identified as a Medcar seconda payer situation. 
The HCFA should pursue legislation to reverse the OBRA 89 mandate which prohibits 
such data matches. 
Propose legislation to require aU insurers to provide their private health insurance dam, 
including eligibility and claims payment information, to RCF A. 
The MSP identification efforts would be greatly enhanced by requiring all insurers to re
port their eligibilty and claims information. The matching of Medicare fies with this pri
vate insurance information could be accomplished by HCFA through a national 
would provide HCFA with maximum capability to identify 
clearnghouse. This system 
MSP situations.  AGENCY COMMENTS

This report is a final version of a management advisory report (MAR) prepar in June 1990 for 
a congressional hearng on the identication and recovery of Medicar seconda payments. 
This report was based on data obtaned during our field work at that point in time. We have 
durg 
completed the review of data obtained  this study, and have issued this final report. 
The HCFA commented in their response to the MAR (see Appendix E) and at an exit conference 
covering this final report that they were generally in agrement with the recommendations, 
except for the matching of contrctor private health insurance records with Medicare fies. 
continue to believe that the matching of records is an importnt fiduciar responsibility of 
Medicare contractors who should reference all sources of information to identify primar payer 
sources.  APPENDIX A

MEDICARE SECONDARY PAYER LEGISLATION 
TITLE OF  PUBLIC  ENACTMENT  EFFECTIVE 
LAW  LAW  DATE  DATE  DESCRIPTION 
Omnibus  96-499  12-05- 12-05- ORA made 
Reconciliation  Medicare the 
Act of 1980  secondar payer 
(ORA)  to automobile 
medcal, no fault 
or any liabilty

insurance. 
Omnibus Budget  97- 08-13- 10-01- OBRAmae 
Reconciliation  Medcare 
seconda payer 
Act of 1981 
(OBRA)  for end-stage 
renal disease for 
up to 12 months 
following 
entitlement if the 
person is eligible 
for medical insurce 
under an EGHP. 
Tax Equity  97-248  09-03- 01-01- TEFRA made 
and Fiscal  Medicare 
Responsibility  benefits 
seconda 
Act of 1982 
(TEFRA)	 if the employee 
or spouse is age 
65 through 69 
covered by an

EGHP and the 
employer has at 
least 20 employees.  -----.- ..- " ------ -
MEDICARE SECONDARY PAYER LEGISLATION

Deficit  98- 369  07-18- 01-01
 DEFRA 
Reduction Act  broadened the 
of 1984  definition of 
(DEFRA)  working spC

by including spouses 
age 65-69 of

employed individuals 
under age 65, 
thereby removing 
the lower age limt. 
Consolidated  98-272  04-06- 05-01 COBRA furter 
Omnibus Budget  broadened the 
Reconciliation  definition of 
working aged by 
Act of 1985

(COBRA)  removing the 
limitation of age 
70 and older. 
Omnibus  99-509  10-21- 01-01 OBRA made 
Budget  Medcare 
Reconciliation  items and 
Act of 1986  servIces 
(OBRA)  secondar for 
payment if the 
disabled beneficiar 
or spouse 
is working 
and covere 
under a large 
group health plan.  MEDICARE SECONDARY PAYER LEGISLATION

Omnibus  101-239  12-19- 12-19
 OBRA provided 
Budget  a two 
Reconciliation  year period for 
Act of 198?  matching 
(OBRA)  IRS ta records

to records of SSA 
and HCFA to identify 
working beneficiares 
and their spouses. 
Omnibus  101-508  11-05- 11-05
 OBRA provided 
Budget  for the extension 
Reconciliation  of the transfer 
Act of 1990  of data from 
(OBRA)  IRS and SSA to 
HCFA through 
September 30, 1995. 
A- 3
 APPENDIX 

MEDICARE SECONDARY PAYER BENEFICIARY SURVEY 
Savings Projections 
Survey Methodology, Response Analysis  and 
Survey Methodology 
The beneficiares selected for the Medicare seconda payer (MSP) survey were selected using a 
simple random sample from the population of all beneficiares purorted to have received 
services some tie durng 1987. A one percent sample of all Medcar beneficiares receiving 
services under Pan B is maintaned by the Offce of Inspector General, Offce of Evaluation and 
Inspections. This me is a subset of the Pan B Medcar Annual Data (BMAD) IV 5 percent 
beneficiar sample file maintaned by HCFA. 
Insurce Clai 
For 1987, this 1. percent sample contans 352,385 separte beneficiar Health 
Numbers (HCN). A subsample of these beneficiares, using sequential sampling, resulte in 
777 HICNs representing beneficiares with Medcar clais. These records were matched 
with the Social Security Admnistrtion s (SSA) Master Beneficiar Record (MR) to obtan 
demogrphic data, including curent addess, and determe the curnt status of each beneficiar 
identified. The following Table 1. 1 gives the results of this matching proess. 
TABLE 
Results of Medicare BMAD IV Match with SSA MBR. 
Orginal Number Selected  777 
Rairoad Retiment Board Beneficiares  138 
Status Indicated as Dead  070 
Non-Matching Numbers 
Final Number of Beneficiares  371 
Railroad Board retiees were deleted from the sample (138 beneficiares) because SSA does not 
maintan their data. The 1,070 beneficiares indicated by SSA to be dead were deleted because 
we chose not to identify or to obtain proxy respondents. The 1,198 mCNs that did not match 
with SSA' s MBR represent a problem encountered with the Beneficiar Identification Code 
(BIC). We were unable to obtan any addess information on these individuals. Therefore, we 
did not contact these individuals. The estimated populations of beneficiares receiving servces, 
based upon the subgroups resulting from the sample, ar given in Table 1. 
.-o,. ---
---.---_. - ------
TABLE 1. 
Estimated Population Sizes 
Sample  Est. Population 
Orginal Sample  777  35,238,500 
Railroad Retirement Board  138  718,800 
Dead  070  563,700 
Non matches  198  229,300 
Survey Contacts  371  728, 
Responden ts  185  16,561, 100 
Non Respondents  186  166,900 
Contacts were made with the remaining 4 371 beneficiares. About 3 weeks later, we followed 
up with those beneficiares who were not responsive to our initial efforts to contat them. A tota 
185 beneficiares had been contacted and responded by March 1, 1990. This represents an 
of 3,
overal response rate of 72.9 percent. 
Paral demographic and utilzation information was gathered frm two soures: 1) the BMAD 
one percent sample and 2) the Medicare Automated Data Retreval System (MARS), also 
maintaned by HCFA. As mentioned earlier, address information came from SSA files. The 
MADRS provided information on tota Pan A and Pan B expenditures on behalf of each 
beneficiar. 
We discussed supplemental medical coverage that an individual might possess as well as any 
accidents in which they may have been involved. Where a beneficiar made a positive response, 
the specific information was developed by OIG field sta to obtan employer and insurrs names 
and addresses. Contacts with employees and insurrs were made to verify whether Medicar 
was the primar or seconda payer. 
Response Analysis 
An importnt consideration in studies of this type is the bias that may be present in the results if 
the non respondents and others not contacte ar different than the respondents. To test for the 
presence of any bias, we compared responders with non responders, for certain varables, in an 
attempt to determine how any observed differences might afect the results. We compared age, 
sex, Pan A reimbursed amounts and Pan B allowed amounts.  Table 2. 1 gives the breakdown of the sample by sex. 
TABLE 2. 
Non  Non

Respondents  Respondents  Matching  Dead

Sex

Male  1192  37.4  512  43.  434  36.  317  32. 
Female  1993  62.  672  56.  764  63.  752  67. 
Unknown 
Tota  3185  1186  1198  1070 
The non respondents tended to have a higher proporton of males while the beneficiares 
determined to be dead have a slightly lower proporton of males, when compared to the 
respondents. Those beneficiares who were not contacted for reasons of non match appear to 
furer
is a 
emulate the respondents with respect to sex. Attached to this appendix, in Table  I, ar 
breakdown of the sub groups, cross tabulatig by age and sex. The average ages  listed at the 
bottom of the tables. For those HICNs that were not matched, no age information was available. 
Table I shows that the average age of the respondents is greater than that of the non respondents. 
For both of the sexes, the age distrbutions ar skewed towards the lower end of the age 
responders when compar to the responders. As might be expected, 
distrbution for the non 
beneficiares determined to have expired were considerably older than both the respondents and 
the non respondents. This table would suggest that age is also a factor in determning the 
response status of a beneficiar.  Table 2.2 presents the average Pan A reimbursement and the average Pan B reimbursement, as 
determined from the MADRS fie, for each of the sub populations included in the sample. 
TABLE 
Average Reimbursement by Sub Population 
Part 
Total  Male  Female  Unkn 
Population  Avg  Avg  Avg 
Responses  746  $6159.  286  $7124.  460  $5558. 
No Response  140  $3766.31  $3659.42  $3864.41 
Non Match  1198 
$64. 
Total  1354  557  $7133.  797  $5962.46 
Part 
Total  Male  Female  Unkn 
Population  Avg  Avg  Avg 
Responses  3185  $1108.  1192  $1259.33  1993  $1017. 
No Response  1184  $437.46  512  $435.  672  $438. 
Non Match  1198  $99.  434  $93.  764  $103. 
Total  6636  $840.  2429  $1019.  4207  $737. 
The unmatched population s Pan A utilization is unkown because they were not found on the 
MADRS fie. For Pan B reimbursed amounts, this table shows both male and female unmatched 
beneficiares used Pan B services sparngly, approximately 10 percent of what the respondents 
use. This is probably why they weren t matched, many of them had no Medicare utilization. We 
Pan 
also compared Pan A and Pan B reimbursed amounts for calenda year 1988. The average 
A reimbursed amount for respondents was $6159.01 and $3766.31 for non respondents, while 
the average Pan B reimbursed amount for respondents was $1108.31 and $437.46 for non 
respondents. Only 12 percent of non responders used Pan A services, versus 23 percent of 
responders. 
Table 2.3 compares respondents, non respondents, dead and unmatched groups by Pan B 
BMA 
allowed amount categories, as determined from the  IV beneficiar sample fie. Included 
in this table are the results of a contingency table analysis to compare the distrbutions of the 
three sub groups, non respondents, non matches and dead beneficiares, with the respondent 
category. The Chi-square value assesses to what extent two distrbutions are alike. The larger 
the value of the Chi-square, the greater the probabilty that the two distrbutions are different. 
B  TABLE 
Distribution of Sampled Beneficiaries

By Part B Allowed Amounts and Response Category

Allowed  Non 
Amount  Respondents  Respo'!1ents  Non Match  Dead 
1.7%  7.3%  158  13. 
$1-$99  638  20.  423  35.  850  71.  375  35. 
$100-$299  658  20.  321  27.  115  136  12. 
$300+  836  57.  354  29.  6.3%  506  47. 
Total  185  1 , 184  198  069 
Chi-Square 
(vs Resp)  550.675  3126.545  238.956 
These results indicate that the thee sub grups not parcipating in the survey ar substantialy 
different with respect to their utilization of Pan B services. Whereas approximately 78 percent 
of the respondents had allowed services in excess of $100, only 57 percent of the non 
respondents, 16 percent of the non matches and 60 percent of the dead beneficiares received 
services in excess of this amount. This result is consistent with the data in Table 2.2. The 
conclusion being that responders to this survey tended to use more services, or more expensive 
services, than the groups not included in the follow up. 

The results of this analysis would indicate that there ar some significant differences between 
those who responded and those beneficiares not parcipating, including the non responders, 
those not matched, and those expirng prior to our contact. Differences exist both by sex and 
age, and with respect to the dollar amounts expended for services on behal of the beneficiares. 
This implies that making projections beyond the responders may not be appropriate and, if made, 
must be qualified with appropriate adjustments. 
Savings Projections

Of the 3, 185 beneficiar contacts, 280 had positive responses requirng follow-up. Additional 
found to exist for 34 respondents. These 
Medicare secondar payer overpayments were 
payments totaled $60,502.04. Thus 1.07 percent of respondents had MSP savings previously 
occurd 
unidentified. Approximately half of the total amount identified  under Pan A (49. 
percent). 
To project these findings to the universe of respondents presents no problem. Projecting our 
results to the other subgroups in the original sample, the non respondents, the non matches and 
representation in our sample. As 
the dead beneficiares, is problematic because of their non 
shown above, there appears to be substantial differences between these subgroups and the 
B - 5  ..-
respondents. However, it may be reasonably assumed that the population of beneficiares who 
did not respond would also have MSP overpayments. 
cert 
In an attempt to project our results to the non pancipating populations, we have made 
assumptions. Since the sample of beneficiares was drwn from the BMA IV Beneficiar 
Sample, we arayed the savings by strta based on Pan B allowed amounts per benefici.: 
Table 2.3, above, shows the breakdown of the subgrups into this 
recorded in this fie. 
stratification. Table 3. 1, below, compars the 34 beneficiares with MSP savings to the sample 
of respondents. 
TABLE 3. 
Distribution of Sample Respondents 
Number in  Number with  Percent with 
Allowed  Sample  Savings  Savings 
Amount 
1.7  1.9 
$1-$99  642  20.  29.4  1.6 
$100-$299  654  20.

$300+  1836  57.  58.  1.1

TOTAL  3185  1.1 
It was also noted in Table 2.3, that the subgroups in the sample vared gratly by these Pan B 
strata. Consequently, the projections developed here ar based upon the strata defined by the 
Pan B allowed amounts. We assumed that those beneficiares in a given strata, as defined in 
Table 3. 1 and regardless of the subgroup in which they were a member, would produce MSP 
overpayments equal to the appropriate strta in the respondents subgroup. Implied in this 
assumption is that all of the other differences identified earlier with respect to age and sex, 
either related to services received, as expressed by the Pan B allowed amount, or unrlated to 
MSP savings. For convenience, the overpayment projections are presented by subgroup so that 
their contrbution to the total may be determined. 
For each strata, an average overpayment per respondent was calculated, with an associated 
standard error. This strata specific average was then applied to the other subgroups. Tota 
overpayment projections represent the sum of the projections across the strta within a subgroup, 
and then across each subgroup. Varances for these estimates were calculated appropriately. 
Table I shows sampled beneficiares by age, sex, and response sub group. Table II includes all 
classes of beneficiares, Table III, beneficiares with working spouses, Table IV, beneficiares that 
are working, and Table V gives savings estimates for beneficiares associated with a disability. 
B - 6
 TABLE I 
Distribution of Sampled Beneficiaries by Age, Sex 
and Response Sub Group 
Respondents  Non Respondents  Dead* 
Male  Female  Male  Female  Male  Female 
c:65  152  12.  109  150  38.  172  32.  6.3  1.7

65- 283  23.  421  21.1  25.  18.4

70- 366  30.  551  27.  16.  118  22.3  15.  10.

75- 223  18.  409  20.  10.  13.  19.  107  14.3

80- 105  288  14.  19.  129  17.

85+  5.3  215  10.  30.  398  53.

Unkn  127  144 
Total  1192  1993  385  528  317  750 
Avge 
70.  74.  69.  72.  78.  84. 
A!!e 
* One dead beneficiary was of unknown sex. 
B  TABLE II

Calculated Savings Total Overpayments All Classes of Beneficiaries

Avg 
Allw amt  Resp  Est Popln  Est Recov 
Reimb 
$1.51  510  275,585  $416,030 
$1-$99  638  $23.  12.727  317,421  $76,997,350 
$100-$299  658  $0.49  0.412  3,421,416  $1,676,494 
$300+  1836  $24.  717  546,686  $235,421,275 
185  $18.  16,561, 108  $314 511, 148 
Non Resp. 
$1.  1.510  447, 176  $675,067 
$1-$99  423  $23.  12.727  199,482  $51,049,967 
$100-$299  321  $0.49  412  669, 110  $817,864 
$300+  354  $24.  717  840,701  $45,391 684 
184  $15.  156,468  $97,934 582 
Non-Match 
158  $1.  510  821,556  240,239 
$1-$99  850  $23.  12.727  4,419,762  $102 582,676 
$100-$299  115  $0.49  412  597,968  $293,004 
$300+  $24.  717  389,979  $9,616,882 
198  $18.  229,265  $113,732,802 
Dead 
$1.  510  270,385  $408, 180 
$1-$99  375  $23.  12.727  949,895  $45,257,063 
$100-$299  136  $0.49  0.412  707, 162  $346,509 
$300+  506  $24.  717  631,058  $64,881,898 
069  $19.  558,501  $110,893,650 
Totals  636  34,505,342  $637,072,181 
L90%  $437,798,254 
U90%  $836,346, 109 
Precision  31.3% 
B - 8  . ---
_._
TABLE 18 
Calculated Savings Total Overpayments Beneficiaries with Working Spouses 
Avg 
:ut  Resp  Est Popln  Est Recov
Allw  Reimb 
$1.  1.510  275,585  $416, 134 
$1-$99  638  $22.46  12.719 ,  317,421  $74,509,284 
$100-$299  658  $0.  0.412  421,416  $1,676,494 
$300+  1836  $21.55  9.364  546,686  $205,731,082 
185  $17 .  16,561,108  $282,332,993 
Non Resp. 
$1.  1.510  447, 176  $675,236 
$1-$99  423  $22.  12.719  199,482  $49,400,356 
$100-$299  321  $0.49  0.412  669,110  $817,864 
$300+  354  $21.55  9.364  840,701  $39,667, 104 
1, 184  $14.  156,468  $90,560,559 
Non-Match 
158  $1.  510  821 556  $1,240,549 
$1-$99  850  $22.46  12.719  419,762  $99,267,855 
$100-$299  115  $0.49  412  597,968  $293,004 
$300+  $21.55  9.364  389,979  $8,404 047 
198  $17.  229,265  $109,205,455 
Dead 
$1.  1.510  270,385  $408,282 
$1-$99  375  $22.46  12.719  949,895  $43,794 642 
$100-$299  136  $0.49  0.412  707, 162  $346,509 
$300  506  $21.55  9.364  631,058  $56,699,307 
069  $18.  558,501  $101,248,740 
Totals  636  34,505,342  $583,347,747 
L90%  $388,500,515 
U90%  $778, 194 979 
Precision  33.4% 
B  TABLE IV

Calculated Savings Total Overpayments Working Aged Beneficiaries

Avg 
Allw amt  Resp  :'t Popln  Est Recov 
Reimb 
$0.  275,585 
$1-$99  638  $0.  0.495  317,421  $2,421 718 
$100-$299  658  $0.  3,421,416 
$300+  1836  $0.  0.366  546,686  $5, 155,210 
185  $0.  16,561 108  $7,576,928 
Non Resp. 
$0.  447, 176 
$1-$99  423  $0.  495  199,482  $1,605,622 
$100-$299  321  $0.  669, 110 
$300+  354  $0.  366  840,701  $993,978 
184  $0.  156,468  $2,599,600 
Non-Match 
158  $0.  821,556 
$1-$99  850  $0.  495  4,419,762  $3,226,426 
$100-$299  115  $0.  597,968 
$300+  $0.  0.366  389,979  $210,589 
198  $0.  229,265  $3,437,015 
Dead 
$0.  270,385 
$1-$99  375  $0.  0.495  949,895  $1,423,423 
$100-$299  136  $0.  707, 162 
$300  506  $0.  0.366  631,058  $1,420,771 
069  $0.  558,501  844 195 
Totals  636  34,505,342  $16,457,738 
L90%  $8,856,625 
U90%  $24 058,850 
Precision  46. 
B  ':,,",..
TABLE V

Calculated Savings Total Overpayments Disabled Beneficiaries 
Avg 
Allw amt  Resp  Est Popln  Est Recov 
Reimb 
$0.  O.()OO  275,585 
$1-$99  638  $6.  410  317,421  $20,435,316 
$100-$299  658  $0.  3,421,416 
$300+  1836  $13.32  673  546,686  $127, 161 856 
185  $8.  16,561 108  $147,597, 172 
Non Resp. 
$0.  447, 176 
$1-$99  423 .  $6.  410  199,482  $13,548,806 
$100-$299  321  $0.  669, 110 
$300+  354  $13.32  673  840,701  $24 518, 136 
184  $6.  156,468  $38,066,942 
Non-Match 
158  $0.  821,556 
$1-$99  850  $6.  4.410  4,419,762  $27,225,734 
$100-$299  115  $0.  597,968 
$300+  $13.32  673  389,979  $5, 194 520 
198  $5.  229,265  $32,420,254 
Dead 
$0.  270,385 
$1-$99  375  $6.  4.410  949,895  $12 011,353 
$100-$299  136  $0.  707, 162 
$300  506  $13.32  673  631 058  $35,045,697 
069  $8.47  558,501  $47,057,050 
Totals  636  34,505,342  $265,141,418 
L90%  $134 970,997 
U90%  $395,311,840 
Precision  49. 
B - 11  ---..----.----.---- - -- -
APPENDIX 

SUMMARY OF IDENTIFIED MSP CASES

Total Respondents = 3, 185 
Total Overpayment Cases = 34 
COST TO 
RESPOND OVER. 
CLASS  CASES  BENEFI 
% OF TOTAL 
ENTS  PAYMENT 
RATIO 
108  $ 1,463.64*  .3 TO 1.0 
105  24%  $54,294.36  90%  10.2 TO 1.0 
$ 4 744.  1.2 TO 1.0 
Totals  280  32%  $60,502.  100%  5.4 TO 1.0 
Class IA includes those respondents who indicated they were working for an employer with 20 
or more employees during 1988. 
Class IB includes those respondents who indicated their spouse worked for an employer with 20 
or more employees during 1988. 
Class IC includes those respondents who indicated that they were involved in either an 
automobile or personal injury accident in 1988. 
Every respondent in these three classes was contac  d to gather additional employment and 
insurance information. This allowed staf to identify and verify actual MSP situations. 
*This includes one disabled beneficiary for whom Medicare paid $14.46. 
C  APPENDIX D

CALCULATIONS OF COST-BENEFIT RATIOS 
The overall cost ratio was calculated as follows: 
Varable Costs

Labor  $9,488. 
Telephone  $114. 
Total Varable Costs$  602. 
Fixed Costs

Rent/ tilities  $615. 
Mailing Costs  085. 
Total Fixed Costs  $1,700. 
Total Varable and Fixed Costs  $11,302. 
Cost-Benefit Ratio 
Total Overpayment  $60,502. 
Total Costs  $11,302. 
Cost-Benefit Ratio  5.4:1 
The cost benefit of developing responses that were identified as working spouses was calculated 
as follows: 
Varable Costs

Total Varable Costs  $ 9,602. 
Total Number of Responses  280 
Cost per Response  $34. 
N umber of Spousal Insurance

Responses  105 
Varable Costs of Spousal Insurance 
Responses  $3,600.45 
D  --------
Fixed Costs 
Total Fixed Costs  $ 1,700. 
Total Varable and Fixed Costs  $ 5,300.45 
Cost-Benefit Ratio 
Total Overpayment on Spousal 
Insurance Responses  $54 294. 
TOtal Costs  $ 5,300.45 
Cost-Benefit Ratio  10.2:1 
The cost benefit of developing responses that were identified as disabled beneficiares was 
calculated as follows: 
Varable Costs

Total Varable Costs  $9,602. 
Total Number of Responses  280 
Cost per Response  $ 34. 
Number of Disabled Beneficiares 
Beneficiar 
. Varable Costs of 
Case Development  $ 891.54 
Fixed Costs

Total Fixed Costs  $ 1,700. 
Total Varable and Fixed Costs  $ 2 591.54 
Cost-Benefit Ratio 
Total Overpayment on Disabled 
Beneficiares  $28,393. 
Total Costs  $ 2 591.54 
Cost-Benefit Ratio  11.0:1 
__n_  APPENDIX 

E - 1
 =:: 
Health Care

Financig Administion 
SERVICES 
DEPARTMENT OF HEALTH Ii HUMAN 
'... t . Ifr  Memorandum 
Date  '1t0 
Gai R. Wiensky, Ph.D. 
trtor 
Frm  dminis
Seconda Payer (MP): 
Management AdVIsory Report "Medicae 
Subject  90-00764) 
Unrecovered Funds" (OEI-07-
The Inpec:or Genera 
Offce of the Secreta 
opponunity to comment on the subject management
Thank you for the 
Offce of the 
The repon restates thee recommendations the 
adviory report 
auditS of the MSP progrm and 
made in separte 
Inpec:or Genera (OIG) 
to each of

offers thr=::: additional recommendations. Our position with respect 
these recommendations is as foI!ows: 
clai 
forms be revised to require 
OIG recommends that Medicae 
HCF A 
spousal insurance information before the claim is paid. 

canC:l  with this recommendation. 
received 
prioritize the inormation 
OIG recommends that HCFA 
cost/enefit ratio. HCFA 
from SSA according to areas of greatest 
recommendation. 
concurs with thi 
propose legilation to establish a 
OIG recommends that HCFA 
Since the initial
voluntary disclosure and recovery program 
they fail to 
provision on debarent of Medficrar e fica agnts if 
HCF A 
dropped  the legislative proposal 
panicipate has be::n 
proposal 
s legislati 
support OIG.
establihig a national data 
consider 
OIG recommends that HCFA 
priar  and their 
insurance data on beneficiares 
system containing  determe the 
believes fuher study is needed to 
spouses. HCF A 
impact of thi proposal
 Page 2 - Inpector Genera 
to requie 
OIG recommends that HCFA propose legilation 
Medicae contrctors to match their pritet hhe alth inurce data 
recommendation, 
with Medicae fies HCF A diagrees with 
because Congres recently pased legilation prohibitig such a 
requiement. We have no reason to believe that Congress has 
th 
isue. 
changed its position on 
OIG recommends that HCF A propose legilation to require an 
inurce 
data includig eligibilty 
inurers to provide their health 
We ar unure 
and claims payment inormation, to HCFA. 
th 
01G.s objeCte. It would appear that  proposal is intended to 
requie inurers to 
give HCFA and OIG stronger authority to 
determe MSP recoveries. In 
provide the inormation necessar to 
th 
caot 
its c  ent form we  agree with  recommendation,
to employers 
because it would be unecessary burdensome both 
wig 
to discus with OIG 
and to HCFA. However, we would be 
th 
how to better frme  proposal to establish such authorities. 
The attached paper discuses each recommendation and provides 
additional commentS on statementS in and the metho  ology of, the subject 
report Please advise us whether you agree with our position on the repon 
recommendations at your earli  st convenience. 
Attachment  . .
Comments of the Health Care Financim! 
dministrtion on the Offce of the 
Second.. 
icare 
JnsDector Genera  eDort on

Paver SP:  90-764 
Unrecovered Funds" OEJ-07-
IG Recommendation

paid. 
inurce 
Revie an Medicae claim form to require spousal  inormation 
before the clai ca be 
RCF A ResDonse 
RCF A bas inormed OIG (in response to eIG Management Adviory Report 
Cai 
wi 
, A-09-89-00100) that we  advie the Uniorm  Form Task Force of our 
clai 
conCUence with thi recommendation to requie spousal inormation on 
Fcr  makg 
form. Tne Uniform Cairn  Task Fan: is responsible for  changes 
to the Medicae claim form. 
OIG Recommendation 2 
Prioritize the information received from SSA ac:ording to these are:a \Tim the 
greatest cost/enefit ratio. 
HCFA ResDonse 
sta  sta 
HCF A  have discussed this issue with eIG  prior to the issuance of 
th 
report We fully agree with  recommendation. As we develop potential 
MSP sitUations with employers, we wm gie priority to situations that appear to 
have the greatest payback, inc1u  ing spousal case development. 
OIG Recommendation 3 
Progr 
Propose legilation to  Volunta Disc10sure and Recovery 
establish a 
HCF A Resuonse

th  (AO-12-89-0). Th 
OIG made  recommendation in a prior report 
progr if 
report contained a proviion to debar Medicae contrctors from the 
progr 
they faed to partcipate in the disclosure  and if the Federa 
governent identifed improper payments In dicussions with OIG, 
sta  - -
, .

. '
J . 
Page 2 
agreed to remove the debarent provion. HCFA now support OIG' 
rewrte it 
legiIa ive proposal and is workig with OIG to 
We believe that the Departent of Health and Human Servces (DHH) and 
the Deparent of Justice (DO!) aleady have authority to anounce a genera 
provions 
amesty from the litigation related to violations of the . :ASP 
suggest that OIG and HCFA consider proposing that, whie the Volunta 
Disclosure and Recovery Progr is being considered by Congress, DHH and 
progr  tht 
DOJ announce a l-year general amnesty  for those other payers 
voluntay repay Medica 
OIG Recommendation 4 
priar 
containg  inurance 
Consider establishig a national data system 
beneficiares and their spouses. 
inormation on al Medicare 
pursue 1egilation to 
HCF A could ac:omplish this by continuing to 
thd par admitrators of 
require insurers, underwters, and 
HCF A about covered individual who are: 
health plans to notif 
over ae:e 65, under 65 and disabled or diae:osed as havine: End 
, and who are enrolled in iIsura. c= progrms to 
Stage Renal Disease
which Medicare is secondar payer. 
broader proposal to 
Altc:Tative!y, this could be absorbed into a  pertg 
esabIih a natioIW clearnghouse of information 
Federa and State 
medica inL'!ncc 
avaiable to beneficiares of al 
health benefit programs. Under this proposal, HCF A would run its 
identi 
clais information though ths clearghouse in order to 
MSP situations. 
HCFA ResDonse 
HCFA is curently fializng a FY 1992 legislatie proposal on inurer reportg 
which wi permt us to obtain more timely MSP inormation. 
The propriety of establihig a national clearghouse is cuently under 
th  fuer 
discussion at the Budget Summt. We intend to discus  issue  with 
Medica-C'l. 
sta to determe potenti 
the Congressional Budget Offce 
assess its impact on 
We do, however, believe that further study is necessar to 
progr  admitered. 
the way our  arc curently  Page 3

orG Recommendation 

prite
their 
Propose legilation to require Medicare contrctors to match 
health inurance data with Medicae fies. 
HCF A Resuonse

requig 
AI prohibits the Secreta from 
Secton 6202( d) of the Social Security 
agait their priate records as a 
the contrctors to perform data matches 

We believe that it would not 
enterig or renewig the contrct. 
condition for  th 
prolu"bition. Congress has 
be prudent or praCtcal to propose elimiation of 
requiement. 
dearly stated its position in opposition to such a 
orG 
Rc:commendation 6 
data 
insurers to provide their health insuranc: 
Propose legislation to require al 
HCF A. 
includig eligl"bilty and claims payment information, to 
HCFA R:suonse 
our legislatie proposal to require inurer 
Ths 
proposal appear to go beyond 
addition, read broadly, the 
Recommendation 4. In 
reponing disCused under 
would be 
unnecessar inormation that 
submission of 
proposal could require the 
s objeCte. 
We arc unsure of 01G' 
burde:lsome both to inurers and to HCF A. 
and CIG stronger authority 
We believe this proposal is intended to gie HCFA 
necessar to. determe the 
to require inurers to provide the information 
 not need 
is cOrTect HCF A does 
amountS of Medicare recoveries. If our belief 
tlUs inormation on an ongoing ,basis. 
al of 
entities 
We would support legilation that would require inurers, and 
plan (including inurers 
responsible for payment under employer group health 
thd par  request from Medicare, to submit 
and  admitrtors), upon 
litations 
pertng  policies, benefit eligibilty, policy 
inormation  to medical 
relatig to their obligations to make 
and exclusions and payment inormation 
priar  Medicae beneficiares. We are 
payment for servces provided to 
wig to discuss with 01G how to better fre th proposal to establih such 
authorities.  , J  Page 4 
General Comments 
BacklZound Statements 
wa 
The repon  , Medicae  always the primar payer 
indicates that, prior to 1980
Medicae beneficiares. Medicae has always been the 
for servc:s provided to 
seconda  ' compensation progrms. 
payer for servces covered by workers
payig for servces authoried 
Medicae alo has always been prohibited from 
progr 
such as the Veterans Admitration. 
by other F edera 
admitrtie 
MSP progr savigs and contractor 
The repon compares 
4 bilon 
The figures cited are $ 1.
exenses for fical year (FY 1987 and 1988. 
in savigs and $115 mIllion in admistrative expenses. The correct figue for 
1 bilon for Par A and $.3 bilon for Pan B in 
MSP savigs is 
S3.3 bilion ($1.
IT  S.s bilon for Pan B in 1988). 
1987 and $1.4 bilon for Par A and 
Estiates 
Me!hodolc  and Savines 
OIG sampled beneficiares were enroIIed in Pan B and rec:ived Medicare 
contai at 
covered se:vic:s in 1987. Ths sample  least tWo sourc:s of e:!ors 
which could cause the sample to underreprent MSP sitUations. Firt, some 
the workig aged and disabilty proviions 
beneficiares who are afected by 
elect not to paridpate in Par B because their employer based coverage is such 
that purchasing Pan B coverage is not cost effectve and because there is no 
penalty for delayed enrollment. Second, some MSP beneficiares were excluded 
priar 
because their  coverage was such that nQ Medicare secondar payments 
were due. There is alo one source of error that could cause beneficiares to 
be falely identifed as MSP beneficiares. Individual enrolled in Par B only 
are not affected by the workig aged or disabilty proviions. Thus 
though their own or a 
employer health plan coverage 
beneficiares with 
Par A 
spouse s employer who are enroIIed in Par B but not covered under 
MSP beneficiares 

should not be considered 
alo 
couId 
The exclusion of the Railroad Retiement Board (RRB) beneficiares 
RR 
estiates. We do not know what proporton ,of  beneficiares 
bias the 
pla  employed individua or if 
have employer heath  coverage as a spouse of an