Mandatory Insurer Reporting

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA Section 111) adds mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation. Who must report? -- Commercial insurers and self-insured entities including pools, captives, group captives, companies with Self-Insured Retention and companies without any insurance. Small companies, with less than 20 employees, who are not part of a collective insurance program in which any member has more than 20 employees (Small Employer Exception) . These entities are collectively known to Centers for Medicare and Medicaid Services (CMS) as Responsible Reporting Entities (RREs). What must be reported by a Group Health Plan (GHP)? RREs must report entitlement information about employees and dependents and an option to exchange prescription drug coverage information to coordinate benefits related to Medicare Part D. CMS is also allowing RREs, that are also participating in the Retiree Drug Subsidy (RDS) program or are reporting to RDS on behalf of a plan sponsor, to use the Section 111 GHP reporting process to submit subsidy enrollment (retiree) files to the RDS Center using the Section 111 GHP reporting process. What must be reported by a workers' compensation, liability or no-fault insurer (Non-Group Health Plan or NGHP)? A NGHP RRE must report information about the insurance plan, payment information, identify the Medicare Beneficiary, define the incident, identify the beneficiary's legal representative and if the beneficiary is deceased, they must identify any claimants and their representatives that are pursuing a settlement on behalf of the estate. Who is a Medicare Beneficiary? CMS distinguishes between an "eligible" and "enrolled" beneficiary. An "eligible" beneficiary is eligible for additional Medicare benefits (e.g., Part B). An "enrolled" beneficiary has a Health Insurance Claim Number (HICN) and may bill Medicare for Part A benefits. Mandatory Insurer Reporting applies to enrolled beneficiaries. If an individual is currently on Social Security Disability Insurance (SSDI), but has not enrolled in Medicare, they are not to be reported. What are the penalties for not reporting? Medicare may assess a penalty of $1,000.00 per day per unreported beneficiary. What is the relationship between Mandatory Insurer Reporting and Medicare Secondary Payer? There has been a great deal of concern and incomplete information about this relationship published in industry news letters and on the Internet. An RRE's compliance with Mandatory Insurer Reporting is satisfied when they report. If they report, they will not be liable for the $1,000.00 per day per unreported beneficiary penalty.