On May 11 the Centers for Medicare & Medicaid Services (CMS) announced another extension of the timetable for the Mandatory Insurance Reporting (MIR) requirements under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 for liability insurance (including self-insurance), no-fault insurance, and workers' compensation plans (non-GHP plans). The major changes were that the registration period, the testing period window, and live production file submissions were all extended by three months. The new implementation timetable for non-GHP responsible reporting entities (RREs) is now:
| 01/01/09-06/30/09 | Recommended systems development period (no change). |
| 05/01/09-09/30/09 | Electronic registration of RREs (previously 5/1/09-6/30/09). |
| 07/01/09 | Query function available for test and production files (previously not announced). |
| 01/01/10-03/31/10 | Testing period for claim input file (previously 10/1/09-12/31/09). |
| 04/01/10-06/30/10 | Initial production claim input file submissions due (previously 1/1/10-3/31/10). |
| 06/30/10 | All RREs will be submitting live production files by this date (previously 3/31/10). |
In December 2007 Congress enacted the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). Section 111(b)(8) amended the Medicare Secondary Payer (MSP) statute to provide for mandatory insurer reporting by liability insurance (including self-insurance), no-fault insurance, and workers' compensation plans. The purpose of these amendments, as expressed by its sponsor, Senator Chuck Grassley (R-IA), on the floor of the Senate, is to "improve the Secretary's [of CMS] ability to identify beneficiaries for whom Medicare is the secondary payer by requiring group health plans and liability insurers to submit data to the Secretary."
Effective July 1 the MMSEA requires that "applicable plans" must first determine whether a claimant (including an individual whose claim is unresolved) is entitled to Medicare benefits. They must report the "required information" once the case is resolved to the Secretary of Health and Human Services in the "form, manner, and frequency" the secretary prescribes.
Additional provisions of the MMSEA state that:
o An "applicable plan" is defined as liability insurance (including self-insurance), no-fault insurance, and workers' compensation laws or plans.
o "Required information" will include the identity of the claimant and other information the secretary specifies it needs to determine coordination of benefits and recovery of claims.
o Timing - The "required information" must be submitted within a time specified by the secretary after the claim is resolved through a settlement, judgment, award, or other payment (regardless of whether or not there is a determination or admission of liability).
A civil penalty of $1,000 for each day of non-compliance is imposed with respect to each claimant. This is in addition to any other penalties prescribed by law. Congress appropriated $35,000,000 to CMS for the next three years in order to implement these reporting requirements.
It is important to note that MMSEA law did not mandate Medicare set-asides for liability claims. It simply added a reporting requirement for insurers, with stiff penalties for non-compliance, and left the details of the "required information" and the "form, manner and frequency" of the reporting up to CMS to announce later.
User Guide and Town Hall Conferences
On March 16 CMS released a user guide for the new requirements mandated by Section 111 of the MMSEA. This guide is 180 pages long and provides an overview of the MSP rules, detailed reporting instructions and file specifications. It essentially codifies all previous CMS announcements on the topic and will be updated as information becomes available. It may be found at https://www.cms.hhs.gov/MandatoryInsRep/Downloads/NGHPUserGuide031609.pdf.
CMS states in the guide that the reporting process will be 100 percent electronic. It will begin with an on-line registration to a secure CMS Web site. Once registered, CMS will assign a representative to work with the RRE to set up the data reporting and response process. RREs will then be assigned a quarterly file submission timeframe during which they are required to submit files.
CMS has set up an optional, on-line query process to assist RREs in determining whether an injured party is a Medicare beneficiary.
CMS has also conducted monthly town hall teleconferences to discuss updated information and answer questions. Scheduled future teleconferences and written transcripts from past teleconferences are available at
CMS has given the industry plenty of lead time and a substantial amount of detail to implement the new reporting requirements. Medicare will also use this information to make sure that insurers are protecting Medicare's interests as a secondary payer as required by previous laws. Hence, not only is it important to comply with these new reporting requirements in order to avoid severe penalties for non-compliance, but it is also imperative to make sure there is compliance with previous rules regarding the determination of Medicare eligibility, resolving conditional payments and Medicare set-aside requirements.
Douglas L. Shaw, C.P.A., C.M.A. is the COO of Medivest Benefit Advisors, Inc., and Medivest Allocation Services, Inc. Medivest provides Medicare set-aside allocations that project a claimant's future medical needs and is a leader in the professional administration of custodial accounts used in settlement of workers' compensation and liability cases. Additional information on the company and Medicare's mandatory reporting requirements is available at Medivest.com.
