1 Beware MMSEA: Are You in Compliance? Bennett L. Pugh Carr, Allison, Pugh, Howard, Oliver, & Sisson 100 Vestavia Parkway Birmingham, Alabama 35216 (205)

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Presentation transcript:

1 Beware MMSEA: Are You in Compliance? Bennett L. Pugh Carr, Allison, Pugh, Howard, Oliver, & Sisson 100 Vestavia Parkway Birmingham, Alabama (205)

2 Medicare, Medicaid, SCHIP Extension Act of 2007 (MMSEA) 42 U.S.C. 1395(y) Section 111 of the act compels mandatory reporting to Medicare by both Group Health Plans (GHP) and Non-Group Health Plans (NGHP) SCHIP is the State Children’s Health Insurance Program MMSEA Overview

3 Two Fold Purpose of Section 111 Assist Medicare with recovery of conditional payments (CPCs) Prevent Medicare from paying when a primary payer exists.

4 Provisions To require GHPs and NGHPs to report to Medicare the existence of any claim involving a Medicare beneficiary To impose a penalty of $1,000 per day per claim for failure to comply To delegate to the Secretary of Health and Human Services the duty to adopt regulations to implement the Act

5 Notification Requirements Beginning July 1, 2009, “liability insurance including self insurance, no-fault insurance and workers’ compensation laws and plans” must report claims involving a Medicare beneficiary to Medicare when the claim is “resolved (or partially resolved) through a settlement, judgment, award or other payment on or after July 1, 2009.” “Must also report on all claims for which the RRE [responsible reporting entity] still has responsibility for ongoing payments for medical services as of July 1, 2009,” such as open medicals in workers’ compensation claims. Subject to timelines, exceptions and lookback provisions

6 Notification Requirements: Medicare Beneficiaries In WC cases with ongoing responsibility for medicals, if payments have been or will be paid after 7/1/09 then the claim is reportable next year even if settled between 7/1/09 and time to report For most GL and WC cases where no payments are made until date of settlement, the claim is reportable if settled on or after 1/1/10 Actual reporting starts in 2010 and there are thresholds for small claims

7 Reporting Timeline Registration for all liability/no-fault/workers’ compensation RREs July 1, Submission of test and production Query Input files begins January 1, March 31, Testing for Claim Input files begins January 1, 2010 – March 31, RREs who have completed testing can submit first Claim Input production files during assigned timeframe April 1, 2010 – June 30, 2010 All RREs are required to begin submitting production files during assigned submission timeframe

8 Penalties No safe harbors and all plans must comply $35m from Congress to implement and enforce Section 111 CMS will hire an “umbrella” contractor to track filings, identify missing reports, and seek payouts