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March 24, 2009

NAMIC Achieves Positive Changes in Medicare Secondary Payer Reporting Requirements

NAMIC achieved three of the association’s goals this week when the Centers for Medicare & Medicaid Services agreed to an extension of time for system testing and initial reporting, a phased-down threshold for total cost obligation, and most significantly, CMS’s reversal of its position regarding the reporting on closed cases.

Attached is the CMS’s User Guide and special Alert. The User Guide provides information on record layout, high-level file submission information, basic information concerning who is a “responsible reporting entity,” what triggers reporting, as well as detailed technical information on registration, testing, file submission, response files, etc. A complete reading of this User Guide and Alert is advised for all companies establishing new reporting and data collection procedures.


On Dec. 29, 2007, President Bush signed S. 2499, the Medicare, Medicaid, and SCHIP Extension Act of 2007, imposing new mandatory information reporting requirements for purposes of coordination of benefits under the Medicare Secondary Payer requirements.

The legislation requires that an applicable plan (including self-insurance, automobile, homeowners insurance, no-fault insurance, and workers’ compensation) determine whether a claimant (including an individual whose claim is unresolved) is entitled to benefits under Medicare and submit information as directed by the federal government with respect to the claimant. CMS published interim record layout information on Oct. 21 and updated the proposals on Nov. 17 and Dec. 5. The new User Guide was published on March 16 and a special Alert was issued on March 20.

NAMIC worked closely with CMS to resolve a number of critical issues prior to initial publication, including the use of third-party reporters, limiting the frequency of reporting, and government documentation of requirements to collect personally identifiable information. NAMIC also worked with CMS to secure insurer access to the Medicare beneficiary database to identify reportable claimants. However, a number of significant legal and operational issues remained and NAMIC worked with CMS, as well as other significant stakeholders, to resolve remaining issues, including closed-case issues and reporting timetables. The User Guide and Alert respond to NAMIC’s concerns.

Testing period and reporting timeline

Initial CMS guidance required insurers to complete the mandatory testing by June 30, 2009, and begin initial reporting on July 1, 2009. In new guidance released on March 20, CMS agreed to extend the testing and reporting requirements through Dec. 31, 2009, and begin live production of data no later than the assigned submission window in the first quarter of 2010. Insurers must register and begin testing prior to June 30, but the extended testing period and delayed reporting requirements will provide insurers additional needed time to comply with the new reporting requirements. Extension of the reporting timetable was a high priority for NAMIC and the association argued that the delays in issuance of the User Guide and other critical guidance made it unrealistic to require compliance by July 1.

Closed cases

Prior guidance issued by CMS required insurers to include information for all claims involving Medicare beneficiaries with a settlement, judgment, award or payment on July 1, 2009, or subsequently in their initial report, as well as information for beneficiaries for which the insurer has an ongoing responsibility for medical payments as of July 1, 2009, for incidents on or after Dec. 6, 1980, regardless of the date of the initial acceptance of financial responsibility. For claims with such ongoing responsibility, CMS acknowledged that insurers may not have access to information for all data elements, but only offered to delay reporting for these claims until the third quarter of 2010.

NAMIC raised legal and operational concerns with reopening closed claims and objected to reporting requirements related to these claims. The March 16 User Guide reflects NAMIC’s concerns and provides that for claims assumed prior to July 1, 2009, if the claim was actively closed or removed from current claims records prior to Jan. 1, 2009, the insurer is not required to identify and report the claim. If such a claim is later subject to reopening, it must be reported with full information, including the original date of injury.

The special exception is a critical improvement in the reporting requirements and is reflective of the priorities of NAMIC members.

Reporting thresholds

NAMIC has consistently urged CMS to adopt a reporting threshold. For liability insurance (including self-insurance), there is no de minimis dollar threshold for reporting the assumption and/or establishment of ongoing responsibility for medicals. However, in new guidance released March 20, CMS has agreed to provide temporary thresholds for reporting of total payment obligations to the claimant (“TPOC”). For liability insurance (including self-insurance) and workers’ compensation TPOCs, the following dollar thresholds apply:

  1. For TPOCs dates of July 1, 2009, through December 31, 2010, TPOC amounts of $0.00 - $5,000.00 are exempt from reporting except as specified n “d’ below.
  2. For TPOCs dates of January 1, 2011, through December 31, 2011, TPOC amounts of $0.00 - $2,000.00 are exempt from reporting except as specified in “d” below.
  3. For TPOCs dates of January 1, 2012, through December 31, 2012, TPOC amounts of $0.00 - $600.00 are exempt from reporting except as specified in “d” below.
  4. Where there are multiple TPOCs reported by the same RRE on the same record, the combined 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.

The changes represent significant improvements in the reporting process. NAMIC will continue to work with CMS and legislators to streamline and simplify the reporting process. If you have any questions regarding the User Guide or the Alert, or Medicare Secondary Payer reporting in general, please feel free to contact Marliss McManus.

Posted: Tuesday, March 24, 2009 12:00:00 AM. Modified: Wednesday, March 25, 2009 8:18:51 AM.

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