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Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare. See 42 U.S.C. 1395y(b) [section 1862(b) of the Social Security Act], and 42 C.F.R. Part 411, for the applicable statutory and regulatory provisions.
Information for Insurers/Self-Insureds regarding MSP Situations
Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added mandatory reporting requirements with respect to Medicare beneficiaries who receive settlements, judgments, awards or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation, collectively referred to as Non-Group Health Plan (NGHP) or NGHP insurance.
The purpose of Section 111 reporting is to enable the Centers for Medicare & Medicaid Services (CMS) to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries. Section 111 NGHP reporting of applicable liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claim information helps CMS determine when other insurance coverage is primary to Medicare, meaning that it should pay for the items and services first before Medicare considers its payment responsibilities.
An organization that must report under Section 111 is referred to as a responsible reporting entity (RRE). In general terms, NGHP RREs include liability insurers, no-fault insurers, and workers’ compensation plans and insurers. RREs may also be organizations that are self-insured with respect to liability insurance, no-fault insurance, and workers’ compensation.
Reporting is accomplished by either the submission of an electronic file of liability, no-fault, and workers’ compensation claim information, where the injured party is a Medicare beneficiary, or by entry of this claim information directly into a secure Web portal, depending on the volume of data to be submitted. Upon receipt of this information, CMS checks whether the injured party associated with the claim report is a Medicare beneficiary, and determines if the other insurance is primary to Medicare. CMS then uses this information in the Medicare claims payment process and, if Medicare paid first when it should not have, uses it to seek repayment from the other insurer or the Medicare beneficiary.
Reporting requirements are documented in a user guide which is available as a series of downloads on the NGHP User Guide page on the CMS website. The NGHP User Guide is made up of five chapters: Introduction and Overview, Registration Procedures, Policy Guidance, Technical Information, and Appendices. Each chapter can be referenced independently, but are designed to function together to provide complete information and instructions for NGHP reporting.
RREs must also be sure to refer to important information published in various alerts on the NGHP Alerts page on the CMS website. To obtain the most up to date information and requirements, refer to the NGHP User Guide and all alerts published subsequent to the current version of the User Guide. Comprehensive Computer-Based Training (CBT) modules covering all aspects of Section 111 reporting can be found on the NGHP Training Material page on the CMS website.