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Sheena Harrison

Medicaid Secondary Payer guidelines continue to roll out

February 20, 2014 - 3:40pm


In addition to considering comments on penalties for Medicare Secondary Payer noncompliance, the Centers for Medicare and Medicaid Services also has issued recent notices about other upcoming changes to Medicare law.

CMS issued a notice on Feb. 11 seeking comments on a proposed process to reconsider Medicare set-aside agreements for workers compensation settlements. Currently, payers have little recourse in asking CMS to re-review a Medicare set-aside that has already been considered for approval by the agency.

The Medicare Secondary Payer Act requires self-insured employers and insurers to act as primary payers for workers comp and liability claims involving Medicare beneficiaries. CMS advises workers comp payers to set up Medicare set-aside accounts to pay for future medical costs for a beneficiary's injury.

Medicare Secondary Payer experts have said that Medicare set-aside amounts approved by CMS can be significantly higher than what insurers or employers initially expect to pay for an injured worker's future medical costs

Under the rules proposed by CMS this month, payers can request that CMS re-review a Medicare set-aside agreement under several circumstances. Those would mathematical errors being found in an approved set-aside agreement, if medical records were mistakenly omitted from a proposed Medicare set-aside, or if the party submitting the Medicare set-aside proposal disagrees with how CMS interpreted a beneficiary's medical records.

Comments for the reconsideration proposal will be accepted by CMS through March 31, and the agency plans to schedule a town hall teleconference about the proposal prior to its implementation.

Meanwhile, CMS issued guidance Tuesday on the minimum threshold for liability settlements that can be deemed eligible for Medicare reimbursement.

The guideline is based on provisions outlined in the Strengthening Medicare and Repaying Taxpayers Act, a bill enacted in January 2013 that aims to ease the Medicare Secondary Payer compliance process. The law requires CMS to set a minimum threshold for Medicare Secondary Payer collections, which would be based on settlements that would be able to cover CMS' cost of recovery for secondary payer cases.

CMS estimates its cost of collection for non-group health plan cases is $335 per case, and that liability settlements of at least $1,000 would be most likely to provide adequate Medicare Secondary Payer recoveries.

Physical "trauma-based settlements of $1000 or less do not need to be reported and Medicare's conditional payment amount for these settlements does not need to be repaid," the notice reads.

CMS will continue to accept comments through Tuesday on another proposed rule for an appeal process related to Medicare Secondary Payer claims.