Changes to the Medicare Secondary Payer Mandatory Reporting Provisions in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA)

Changes to the Medicare Secondary Payer Mandatory Reporting Provisions in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA)

As we predicted, there have been some important changes or clarification from CMS. We wanted to make you aware of these new developments related to the liability and worker's compensation portion of Medicare's mandatory reporting requirements.

First, a NEW acronym – NGHP – Non Group Health Plan. This really includes insured and self-insured liability plans, and worker's compensation plans.

Second, some deadlines and dates have changed.

A. Extension of Registration Period

The registration period for RREs has been extended from May 1, 2009 through September 30, 2009.

B. Change/Delay in Testing Period for the Claim Input File and in the Start Date for the Live Production Submission of the Claim Input File:

· All RREs must submit their first live production file no later than their assigned submission window for the April – June calendar quarter of 2010 (the beginning of window changed from January 1, 2010).

· Testing for the submission of the Claim Input file will now take place from January 1, 2010 through March 31, 2010 (the window changed from July 1, 2009 through December 2009).

C. Start Date for Query Function Availability

The Query Function will be available as of July 1, 2009, for those RREs who have completed registration and are in testing status. An RRE cannot use the query process until it has registered. Remember, if you don't have anything to report, there is no need to register. We advise you not to register just so that you can query.

D. Exception Regarding TPOC Reporting Dates and Reporting for Multiple TPOC Amounts Where the Reporting Threshold is a Consideration

· Section 111 reporting will not include the reporting of TPOC amounts with dates prior to January 1, 1010. Note that dates associated with reporting ORM have not changed.

· Where a TPOC amount dated on or after January 1, 2010 falls below the threshold amount, the RRE must add all associated TPOC amounts dated on or after January 1, 2010 in determining if the reporting threshold is met.

Third, Interim Reporting Thresholds.

There are some new threshold amounts that determine if and what you need to report.

A. For worker's compensation ORM, claims meeting all of the following criteria are excluded from reporting for file submissions:

1. "Medical only"

2. "Lost time" of no more than 7 calendar days.

3. All payment(s) has/have been made directly to the medical provider.

4. Total payment does not exceed $600

B. For liability insurance (including self-insurance) and worker's compensation TPOCs, the following dollar thresholds apply:

1. For TPOC dates of July 1, 2009 through December 31, 2010, TPOC amounts of $0 - $5,000 are exempt from reporting except as specified in 4, below.

2. For TPOC dates of January 1, 2011 through December 31, 2011, TPOC amounts of $0 - $2,000 are exempt from reporting except as specified in 4, below.

3. For TPOC dates of January 1, 2012 through December 2012, TPOC amounts of $0 - $600 are exempt from reporting except as specified in 4, below.

4. Where there are multiple TPOCs reported by the same RRE on the same record, the confined TPOC amounts must be considered in determining whether or not the reporting exception threshold is met. For TPOCs involving a deductible, where the RRE is responsible for reporting both any deductible and any amount above the deductible, the threshold applies to the total of these two figures.

We want to caution you that these are threshold levels for Section 111 reporting and do not apply to any responsibility that currently exists regarding other Medicare Secondary Payer provisions such as the need to obtain Medicare Set-Aside Agreements.

If you would like to talk about these issues or feel you need further guidance, please contact Ann Stewart of Ice Miller LLP.

This publication is intended for general information purposes only and does not and is not intended to constitute legal advice. The reader must consult with legal counsel to determine how laws or decisions discussed herein apply to the reader's specific circumstances.