New Medicare Reporting Requirements for the 15K Program

written on August 10, 2009 by COSEWorkersCompensation contributor

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Employers who participate in the $15K program should have received a letter from the BWC in mid-March 2009 advising that there are new reporting requirements imposed by Medicare related to the $15K Medical-only Program through the Ohio BWC.  Section 111 of the Medicare, Medicaid and SCHIP Extension Act was approved by Congress in December 2007, and Medicare is now requiring compliance with this part of the Act. 

The Medicare Secondary Payer provisions under Section 111 require employers in the BWC $15K program to report the identity of an employee who is a Medicare recipient, or who was eligible for Medicare and was injured at work.  Medicare recipients include individuals age 65 and over, certain disabled persons, and those with permanent kidney failure.

An employer may do their own reporting, or contract with an RRE (Responsible Reporting Entity) to do the reporting on their behalf.  However, an employer is to register themselves and then reporting can be done by the RRE.  Please keep in mind that you can elect to have this reporting done on your behalf, but you do need to weigh the costs associated with this contract against the amount of actual reporting you may or may not need to make.

Employers who participate in the BWC $15K Program are considered by Medicare to be part of an  NGHP - Non-Group Health Plans.

The website for information is http://www.cms.hhs.gov/MandatoryInsRep/

Timeline:

  • 05/01/09 - 09/30/09 - electronic registration via COBSW for workers' compensation RREs
  • 04/01/2010 - All Workers' Comp RREs submit first Section 111 production Claim Input files based upon a predetermined scheduled with the COBC
  • 06/01/2010 - Medicare reporting start
  • 07/01/2010 - all Workers' Comp RREs will be submitting their Section 111 Production Claim Input Files

While there is a hefty fine ($1,000 per day) for not reporting claims on time, the reporting can be done on-line and only pertains to claims involving injured workers who may be Medicare eligible.  The employer is obligated to report ongoing responsibility for medicals (ORM) when the ORM is assumed - that is when you either agree to pay medical, or you are ordered to do so by the BWC/IC.

When reporting a claim, the social security number is the key field, although you will be asked for the name, date of birth, and gender of the injured worker.

CMS (Centers for Medicare & Medicaid Services) is NOT providing free software for submitting claim input files, only for queries.

For Workers' Compensation ORM (Ongoing Responsibility for Medicals), claims meeting all of the following criteria are excluded from reporting for file submissions due through December 31, 2010:  Medical only claims with lost time of no more than 7 calendar days; all payments have been made directly to the medical provider; and total payments do not exceed $600.

ABBREVIATIONS:

CMS:  Centers for Medicare & Medicaid Services

NGHP:  Non-Group Health Plan

ORM:  Ongoing Responsibility for Medicals

RRE:  Responsible Reporting Entity

You can go in the website indicated above, and review information pertaining to NGHP employers (it is included in the Liability Insurance bullet point on the left side of the page).  Information and timelines are continuing to change and we will keep you informed of any changes.

From Pat Ryba
COSE Compensation Services