Blogging Employee Benefits

February 24, 2006

Interim Regs on Medicare Secondary Payer Amendments

Filed under: CMS, Healthcare, Medicare, Regulations — Fuguerre @ 7:22 am

Medicare may also seek reimbursement from any entity that has received payment from a primary payer. Entities that receive payment include, but are not limited to beneficiaries, attorneys, and providers or suppliers (including physicians).

Interim regulations implementing Medicare Secondary Payer (MSP) amendments made by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) have been published by Centers for Medicare & Medicaid Services (CMS). [42 CFR 411 and 489, 71 FR 9466] The new rules clarify various MSP definitions and rules, including the legal basis for collection of amounts from employers and other entities payments made by Medicare to providers when Medicare coverage should have been secondary.

A primary payer and any entity that receives payment from a primary payer is obligated to reimburse CMS once primary payment responsibility has been demonstrated. That obligation is not eliminated if the primary payer has paid the wrong party, such as by paying the Medicare beneficiary or the provider when it ought instead to have reimbursed the Medicare program.

Where a group health plan or large group health plan is the primary payer, all employers that sponsor or contribute to the group health plan have a reimbursement obligation to Medicare, regardless of whether the plan is insured or self-insured. Self-insured status may be demonstrated by the failure to obtain insurance, among other ways.

Reimbursement is not required if Medicare has already recovered payment. However, Medicare is not required to pursue the entity that received payment before it pursues the primary payer for reimbursement.

Although technically the MMA amendments clarify MSP provisions effective as if enacted in 1980 with the original legislation, the interim regulations are effective 4/25/06. Comments on the interim regulations should be submitted to CMS by 4/25/06.

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