Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added 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.
The provisions for Non-Group Health Plans (NGHP), such as Workers’ Compensation claims, is found at 42 U.S.C. 1395y(b)(8). Reporting requirements are documented in the NGHP User Guide which is available as a series of downloads on the NGHP User Guide page. The NGHP User Guide is the primary source for Section 111 reporting requirements.
An organization that must report under Section 111 is referred to as a responsible reporting entity (RRE). In general terms, NGHP RREs include liability insurers, no-fault insurers, and workers’ compensation plans and insurers.
Failure to perform the required Section 111 reporting at all within one year of the date a settlement or other payment obligation provides for a monetary penalty of up to $1,000 for each day of noncompliance for each individual whose information should have been reported. This penalty amount will be adjusted annually for inflation under 45 CFR part 102. Current maximum penalty amount as adjusted for inflation in 2023 is $1,247.
CMS has just release of the latest iteration of the Non-Group Health Plan User Guide – Version 7.3. According to the firm of Allan Koba, Version 7.3 contains three main revisions:
First, and arguably the most significant, Chapter III has been updated to attempt to add some detail to the section on Ongoing Responsibility for Medical (ORM) reporting – Section 6.3.
These changes aim to clarify what triggers Ongoing Responsibility for Medical (ORM) reporting. In a prior update, this section was expanded, adding a conjunctive, 2-part test for the trigger of ORM. That is, in Version 7.2, the trigger for ORM was the assumption of ORM by the RRE AND the beneficiary receiving medical treatment for the related injury. This update caused questions from our industry, including how and when an RRE should know about medical treatment.
In response to these questions, the agency has released the updates of Version 7.3 which has removed use of the word “and”, applying a new definition which now states that the trigger for Ongoing Responsibility for Medical (ORM) reporting is the determination to assume ORM which is when the RRE learns, through normal due diligence, that the beneficiary has received claim-related treatment.
These changes to the text effectively remove the decision-making power from the RRE to decide when Ongoing Responsibility for Medical (ORM) has been accepted, and has defined acceptance as knowledge of claim-related treatment.
Secondly, Chapter IV has been updated to inform users who have opted into the unsolicited response file process that they may receive an empty file if no updates were made to their records in a given reporting period. That is, if an RRE has opted to receive the unsolicited response file, it will still receive a blank response file if no updates have been made by outside parties that would/should be contained therein. While the issuance of empty unsolicited response files was previously announced via an Alert last month, the fact that an empty file may be received is now outlined in Ch. IV, Sect. 7.5 for future reference.
Chapters I, II, and IV have been revised to remove all references to Internet Explorer as it is no longer a supported browser. While this update likely does not make too many waves, it may be of interest to some carriers utilizing a reporting software that was designed for IE.
Each chapter of the updated 7.3 User Guide is available for download. For questions about these updates, as well as general inquiries about Section 111 reporting and all things Medicare Secondary Payer, readers may contact Allan Koba at info@allankoba.com.