94-1978. Medicare Program; Medicare Secondary Payment

[Federal Register Volume 59, Number 20 (Monday, January 31, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-1978]


[[Page Unknown]]

[Federal Register: January 31, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES
[BPO-094-GN]
RIN 0938-AF05

 

Medicare Program; Medicare Secondary Payment

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: General notice.

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SUMMARY: This notice provides guidelines for complying with 42 CFR 
411.25, which provides that certain third party payers for health 
services furnished to Medicare beneficiaries must furnish certain 
information to Medicare intermediaries and carriers when they learn 
that Medicare made primary payment for services for which the third 
party payer has made or should have made primary payment. The notice 
also informs third party payers that they should contact HCFA if they 
wish to discuss arrangements for exchanging, on a voluntary basis, data 
about beneficiaries for whom the third party payer has a primary 
payment obligation under the Medicare Secondary Payer (MSP) provisions 
of the Medicare law.
    The third party payers affected by this notice are workers' 
compensation plans and insurers; all liability and no-fault insurers, 
including automobile insurers; and group health plans under certain 
circumstances, including plans which are self-insured and/or self-
administered. If the group health plan, or workers' compensation plan 
is self- insured and self-administered, the employer must provide the 
notice; otherwise the insurer, underwriter or third party administrator 
must give the notice. This description of information third party 
payers must furnish is intended to help ensure that, in accordance with 
the Medicare law, Medicare pays only secondary to primary coverage of 
third party payers.

EFFECTIVE DATE: This notice is effective for Medicare claims paid on or 
after April 1, 1994.

FOR FURTHER INFORMATION CONTACT: Cathy Carter, [phone].

SUPPLEMENTARY INFORMATION:

Background

    One of the priorities of the Department of Health and Human 
Services (HHS) is to encourage high quality and effective health care 
while pursuing strategies to contain or moderate health care costs and 
Medicare expenditures. When Medicare was originally enacted, Medicare 
was the primary payer, except where services were covered under a 
workers' compensation plan. However, since 1980, Congress has made 
additional third party payers subject to the Medicare secondary payer 
law (section 1862(b) of the Social Security Act (the Act)). Under 
current law, Medicare is the secondary payer where services are covered 
by:
    1. A workers' compensation law or plan;
    2. No-fault insurance, including automobile no-fault;
    3. Any liability insurance policy, or plan, including an automobile 
liability insurance policy or plan;
    4. Group health plans during a period (generally up to 18 months) 
when an individual is entitled to Medicare based on end-stage renal 
disease;
    5. Group health plans where the Medicare beneficiary is employed by 
an employer of 20 or more full or part-time employees, and is age 65 or 
over, or is age 65 or over and the spouse of an individual of any age 
employed by an employer of 20 or more full or part-time employees; and
    6. Large group health plans (plans of one or more employers where 
at least one of the employers has 100 or more full or part-time 
employees) in the case of a disabled individual whose coverage is based 
on his or her current employment or on the current employment of a 
family member.
    The Medicare secondary payer regulations at 42 CFR part 411 
describe these provisions in detail, except for their application to 
disabled beneficiaries. The Omnibus Budget Reconciliation Act of 1993 
(Pub. L. 103-66) makes the disabled beneficiary provision similar to 
that of the working aged, effective August 10, 1993. Final rules are 
currently being developed which will take into account changes in law.
    Although the provisions of the law and regulations clearly identify 
those situations in which payers are primary to Medicare for particular 
beneficiaries, information on file and information submitted with 
individual claims does not always indicate that multiple payment 
sources are available. Consequently, Medicare intermediaries and 
carriers sometimes mistakenly make conditional primary payments when 
another payer should pay primary.
    Our regulations at 42 CFR 411.25 (upheld by the U.S. District Court 
for the District of Columbia in Blue Cross and Blue Shield Association 
v. Sullivan, No. 90-1528 (RCL) (D. D.C. April 7, 1992), appeal filed, 
(D.C. Cir. May 22, 1992)) specify that a third party payer must give 
notice to Medicare if it learns that Medicare has made a primary 
payment in a situation where that third party payer made or should have 
made the primary payment. A third party payer is considered to learn 
that Medicare has made a primary payment when the third party payer 
receives information that Medicare had made a primary payment, or when 
it receives information sufficient to draw the conclusion that Medicare 
has made a primary payment. Examples include, but are not limited to, 
the following:
    1. The third party payer has received a copy of an Explanation of 
Medicare Benefits (EOMB) form, and the EOMB shows that Medicare has 
made a primary payment for services for which the third party has made, 
or ought to have made, primary payment.
    2. A beneficiary for whom Medicare should be secondary payer states 
in correspondence provided to the third party payer that Medicare has 
made primary payment for a given item or service for which the 
beneficiary has primary coverage under the third party payer's plan.
    3. A beneficiary who is eligible for Medicare files a claim for 
primary payment with a third party payer, the claim is denied, the 
beneficiary appeals, and the denial is reversed. (The third party payer 
should assume that Medicare made a conditional primary payment in the 
interim.)

Third Party Payer Reporting Requirements

    42 CFR 411.25 requires a third party payer to notify HCFA when it 
learns that Medicare has made conditional primary payment for items or 
services for which the third party payer has made or should have made 
primary payment. We intend to use reported information to--
     Update and correct information in our system of records 
regarding MSP situations;
     Identify and recover any conditional primary payments made 
for items and services which have been paid for or could be paid for by 
a primary payer.
    This notice is directed to--
     Workers' compensation plans and insurers;
     Liability and no-fault insurers, including automobile 
insurers; and
     Group health plans and large group health plans--their 
insurers, underwriters, and third party administrators; and sponsoring 
employers, employee organizations, and similar groups.

General Notice Requirements

    As required by Sec. 411.25(a), any third party payer that learns 
that a Medicare intermediary or carrier has made a Medicare primary 
payment for items or services for which the third party payer has made 
or should have made primary payment, must give notice to that effect to 
the Medicare intermediary or carrier that paid the claim. The notice 
should be directed to the attention of the Medicare Secondary Payer 
Coordinator. As required by Sec. 411.25(b), the third party payer must 
describe the specific situation, the circumstances, and the time period 
for which the third party payer may be primary to Medicare.
    In instances where the third party payer does not know which 
Medicare intermediary or carrier paid the claim, the third party payer 
should contact the HCFA regional office which services the State in 
which the provider or the physician or other supplier is located. The 
regional office can provide the name and address of the appropriate 
intermediary or carrier. Following is a listing of the HCFA regional 
offices, their addresses, telephone numbers, and the States they 
service. 

------------------------------------------------------------------------
          Regional Office                       States served           
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HCFA Regional Office, ATTN: MSP      Connecticut, Maine, Massachusetts, 
 Coordinator, John F. Kennedy         New Hampshire, Rhode Island,      
 Federal Building, 23rd Floor,        Vermont.                          
 Boston, MA 02203, [phone].                                      
HCFA Regional Office, ATTN: MSP      New Jersey, New York, Puerto Rico, 
 Coordinator, 26 Federal Plaza,       Virgin Islands.                   
 Room 3811, New York, NY 10278,                                         
 [phone].                                                        
HCFA Regional Office, ATTN: MSP      Delaware, District of Columbia,    
 Coordinator, 3535 Market Street,     Maryland, Pennsylvania, Virginia, 
 Room 3100, Philadelphia, PA 19101,   West Virginia.                    
 [phone].                                                        
HCFA Regional Office, ATTN: MSP      Alabama, Florida, Georgia,         
 Coordinator, 101 Marietta Street,    Kentucky, Mississippi, North      
 Suite 701 Atlanta, GA 30323, (404)   Carolina, South Carolina,         
 331-2240.                            Tennessee.                        
HCFA Regional Office, ATTN: MSP      Illinois, Indiana, Michigan,       
 Coordinator, 105 West Adams          Minesota, Ohio, Wisconsin.        
 Street, 15th Floor, Chicago, IL                                        
 60603-6201, [phone].                                            
HCFA Regional Office, ATTN: MSP      Arkansas, Louisiana, New Mexico,   
 Coordinator, 1200 Main Tower         Oklahoma, Texas.                  
 Building, Room 2000, Dallas, TX                                        
 75202, [phone].                                                 
HCFA Regional Office, ATTN: MSP      Iowa, Kansas, Missouri, Nebraska.  
 Coordinator, New Federal Office                                        
 Building, 601 East 12th Street,                                        
 Room 235, Kansas City, MO 64106,                                       
 [phone].                                                        
HCFA Regional Office, ATTN: MSP      Clorado, Montana, North Dakota,    
 Coordinator, Federal Office          South Dakota, Utah, Wyoming.      
 Building, 1961 Stout Street, Room                                      
 574, Denver, CO 80294, (303) 844-                                      
 6149 ext. 0.                                                           
HCFA Regional Office, ATTN: MSP      American Smaoa, Arizona,           
 Coordinator, 75 Hawthorne Street,    California, Guam, Hawaii, Nevada. 
 4th Floor, San Francisco, CA                                           
 94105, [phone],.                                                
HCFA Regional Office, ATTN: MSP      Alaska, Idaho, Oregon, Washington. 
 Coordinator, 2201 Sixth Avenue, RX                                     
 40, Seattle, WA 98121, (206) 553-                                      
 2350.                                                                  
------------------------------------------------------------------------

Liability, No-Fault and Workers' Compensation Insurers

    In order to meet the requirements of Sec. 411.25, workers' 
compensation plans and insurers (including employers in the case of 
self-insured and/or self-administered plans), liability insurers 
(including automobile liability insurers), and no-fault insurers 
(including automobile no-fault insurers) must provide the following 
information to the Medicare intermediary or carrier that paid the claim 
when the third party payer learns that Medicare has mistakenly made a 
primary payment for services for which the third party payer has 
primary payment responsibility:
    Medicare Beneficiary Information:
 Beneficiary name, address, sex, and date of birth
 Beneficiary health insurance claim number (i.e., Medicare 
beneficiary identification number or ``HIC number'')
 Social security number (if known)
    Medicare Claim Information:
 Date of accident, injury, or illness
 Provider of service
 Amount of Medicare payment (if known)
 Date of service
 Date of Medicare payment (if known)
    Insurer, Employer, or Administrator Information:
 Policyholder name and address
 Name and address of insurer or administrator
 Policy identification number or other identifier
 Individual case identifiers used by third party payer (if 
applicable)
 Name and phone number of insurer or administrator contact 
person
 Workers' compensation agency claim number (if applicable)
 Court case or docket numbers (if applicable)
 Beneficiary's attorney's name, address and phone number (if 
known and applicable)
 Name, address, and phone number of employer
 Date and amount of payment (specify whether undisputed 
payment, settlement of disputed claim, or judgment)
 Whether, under the plan or insurance, payment was considered 
to be a primary or a secondary payment
 Payee name and address

Employer and Employee Plans

    In order to meet the requirements of Sec. 411.25, insurers, 
underwriters, third party administrators of group health plans and 
large group health plans, and employers (in the case of self-insured 
and/or self-administered plans) must provide the following information 
to the Medicare intermediary or carrier that processed the claim when 
they learn that Medicare has mistakenly paid primary for services for 
which the third party payer should be the primary payer--
    Medicare Beneficiary Information:
 Beneficiary name, address, sex, and date of birth
 Beneficiary health insurance claim number (i.e., Medicare 
beneficiary identification number or ``HIC number'')
 Social security number (if known)
    Medicare Claim Information:
 Date of accident, injury, or illness
 Provider of service
 Amount of Medicare payment (if known)
 Date of service
 Date of Medicare payment (if known)
    Employer Health Plan Information:
 Policyholder name and address (usually, the employee)
 Beneficiary's relationship to policyholder (self, spouse, 
other)
 Insurer, underwriter, or third party administrator name and 
address
 Sponsoring employer or employee organization name and address
 Group identification number or other identifier
 Policy identification number or other identifier
 Individual beneficiary identifiers (if unique identifier used 
by employer group health plan)
 Name and phone number of contact person
 Period during which the individual was covered under the group 
health plan. If the coverage is still in effect, this fact must be 
stated.
 Date and amount of payment
 Whether, under the plan or insurance, payment was considered 
to be a primary or a secondary payment
 Payee name and address

Incomplete Information and Continuing Duty to Report

    In the event that a third party payer does not have all the items 
of information designated, it should still report the information it 
does have, and certify that it has no other information. In the event 
the third party payer subsequently obtains a previously unreported item 
of information, it must report such information unless the third party 
payer knows that Medicare has recovered the full amount of the primary 
payment the third party was obligated to pay, or the Medicare payment, 
if less.

Voluntary Reporting of Possible Medicare Secondary Payment Situations

    Medicare has established a routine use of information within its 
Privacy Act systems of records (Privacy Act of 1974; Matching Program, 
55 FR 37549, September 12, 1990). This routine use allows a mutually 
beneficial exchange of information concerning matched individuals. 
Mutual exchange of MSP information is in the interest of all parties 
because it can prevent confusion, mistakes, and possibly costly 
disputes. If, after reviewing the routine use notice, your organization 
is interested in voluntarily reporting or exchanging MSP information, 
please write to HCFA at the following address for information: Health 
Care Financing Administration, Bureau of Program Operations, Division 
of Entitlement and Benefit Coordination, Meadows East Building, room 
368, 6300 Security Boulevard, Baltimore, Maryland 21207, Attn: Ms. 
Patricia Talley, [phone].

Information Collection Requirements

    The information collection requirements contained in this notice 
required by 42 CFR 411.25 were approved and assigned Control Number OMB 
0938-0564 by the Executive Office of Management and Budget under the 
authority of the Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et 
seq.).

    Authority: Section 1102 of the Social Security Act (42 U.S.C. 
1302)

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: January 24, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 94-1978 Filed 1-28-94; 8:45 am]
BILLING CODE 4120-01-P