Medicare Secondary Payer: 2021 Year End Review

DECEMBER 20, 2021

Interested stakeholders need to stay abreast of the many changes in Medicare Secondary Payer compliance.  Here are some of the issues to be aware of as we end 2021.

PAID Act Implementation

Medicare Advantage Plans and the identification of their conditional payment interests have challenged parties since their inception.  Under current processes, the CMS and their contractor will only make parties aware of Medicare Part A and B conditional payments.  This will change on December 11, when the PAID Act becomes effective.

The “Provide Accurate Information Directly Act” or “PAID Act” will require CMS to identify conditional payments made by Medicare Advantage Plans (Part C) and Part D prescription drug plans.  Starting in mid-December, additional information will be accessible via the Workers’ Compensation Medicare Set-aside Portal (WCMSP) that will include:

•  Whether a claimant subject to the query is, or during the preceding 3-year period has been, entitled to benefits under the program under this title on any basis; and

•  The plan name and address of any Medicare Advantage plan under part C and any prescription drug plan under part D the claimant is enrolled or has been enrolled during such period.

This will be a welcome change that will promote settlement by identifying all conditional payments made on behalf of a Medicare beneficiary.

SMART Act Update: Conditional Payments Recovery Thresholds

CMS is expected to release guidance on conditional payment recovery thresholds for all Non-Group Health Plan (NGHP) lines of business - workers’ compensation, general liability, and no-fault insurance claims.  This annual announcement resulted from the passage of the SMART Act and was due on November 15.  It is unclear why there is a delay, but it is expected CMS will maintain their $750 threshold for conditional payment recovery. 

WCMSA Legislation in 2022

The Coordination of Medicare Payments and Workers’ Compensation Act – COMP Act (S. 653) is currently pending in Congress.  While the passage of this bill is uncertain, it would be a welcome change to the voluntary workers’ compensation Medicare set-aside (WCMSA) review and approval process by Medicare.  If this bill were to become law, it would make the following changes:

• Codify essential industry terms and define under the statute a “Medicare Set-aside;”

• Create in statute a legally recognized safe harbor that will allow parties to resolve their workers’ compensation claims involving Medicare with absolute certainty;

• Recognize the use of the optional proportional adjustment of a Medicare Set-aside;

• Require the recognition of state law and rules related to workers’ compensation settlements.  Under current processes, CMS is free to add additional requirements to state statute of limitations, etc.; and

• Create a formal appeals process following a counter-higher approval of a Medicare Set-aside.

There is no clear path in Congress for this bill to become law.  It is important to be aware of possible change as nothing is certain in the current political environment.

Conclusions

MSA Source remains committed to providing passion driven results to its clients. Feel free to contact us if you have any questions on these changes, as we are committed to being an industry leader in Medicare Secondary Payer compliance services and education.