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Medicare Eligible Opt-Out Payment Employee AcknowledgmentAn opt-out payment to a Medicare eligible employee is prohibited for employers of 20 or more employees because they are considered prohibited incentives under Medicare Secondary Payer rules, unless the active employee has their own coverage or coverage through a spouse that is primary to Medicare.I, ____________________________________, have read and acknowledge all of the following are true:I am eligible for Medicare;I am electing to receive the opt-out payment available from [Employer group health plan] for eligible employees who do not enroll in the employer provided coverage; andI am currently enrolled in other major medical coverage, either individually or through my spouse, that is primary to Medicare. Employee SignatureDatePrinted Name ................
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