The Centers for Medicare and Medicaid Services (CMS) issued the latest version of its MMSEA Section 111 user guide for Non-Group Health Plans (NGHPs) on July 3, 2012.

This version has taken historical “alerts” and incorporated new reporting options for workers’ compensation, total payment obligations to claimants (TPOC), and updates from the technical applications and guidance on “Who Must Report” and “Reporting Thresholds.”

CMS reorganized the user guide, which is available at www.CMS.gov/mandatoryinsrep, into five chapters, providing easier access and topic search. (Follow the menu on the left side of the page to “NGHP User Guides.”)

Workers’ Compensation Ongoing Responsibility for Medical (ORM) Threshold Extended

Although, the workers’ compensation ORM threshold was expected to expire this year, CMS has extended it. Workers’ compensation claims that meet ALL of the following criteria are excluded from reporting until further notice:

• The claim is for “medicals only;” and
• The associated “lost time” is no more than the number of days permitted by the applicable workers’ compensation law for “medicals only” (or seven calendar days if applicable law has no such limit); and
• All payment(s) has/have been made directly to the medical provider; and
• Total payment for medicals does not exceed $750.

Reporting Threshold for TPOC Settlements Revised

Beginning January 1, 2012, RRE’s were to begin reporting TPOC settlements, judgments, awards, or other payments over $100,000. This threshold diminishes throughout the year. The complete reporting threshold dates are as follows:

*Within the quarter beginning on this date.

Note the minimum threshold of $5,000 will remain throughout 2013.

CMS has also revised the mandatory TPOC thresholds for workers’ compensation as below:

*Within the quarter beginning on this date.

About MMSEA Section 111 for Non-Group Health Plans

MMSEA Section 111 adds mandatory reporting requirements for Medicare beneficiaries who receive settlements, judgments, awards, or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation. The reporting requirements for NGHPs became effective on July 1, 2009. All responsible reporting entities (RRE) should have registered by this date.

This legislation is an extension of the “Medicare Secondary Payer” Act of 1980. Its intent is to protect the financial assets of the Medicare program. The legal position taken by CMS is based on those instances when a Medicare beneficiary seeks medical treatment for injuries caused by another party.

In those cases, Medicare is “secondary” for responsibility in payments for the treatment obtained and payments owed. If you are considered the RRE, you are required to report these cases based on the guidelines found in the MMSEA Section 11 user guide.

How Marsh Can Help

Compliance with MMSEA Section 111 and the mandatory insurer reporting process should be incorporated within your claim management best practice.

Marsh is able to assist clients with any questions about or performance of vendors that provide MMSEA Section 111 compliance services. We can also assist you with developing a comprehensive approach to reducing costs with your general, product, auto liability, and workers’ compensation claims and risk management programs.

For more information about this issue and our solutions, please contact your local Marsh or Marsh Risk Consulting representative or one of these experts:

Gary Bruce
Marsh Claims Practice
Marsh
Phone: 317.261.9316
Email: gary.bruce@marsh.com

Mary Ellen McLean
Complex Liability Consulting
Marsh Risk Consulting
Phone: 313.393.6741
Email: maryellen.mclean@marsh.com

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