Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA Section 111) adds mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation.

Review Mandatory Insurer Reporting (MIR) for a more detailed description or see the Overview of MIR and MSP for a discussion of the difference between the two CMS statues.

Group Health Insurance (GHP)

GHP reporting is much as it was under the VDSA process.  Health Savings Accounts (HRA) must also be reported as a GHP, although HRAs below $5,000 in annual benefits are exempt (as of 2012).

Non-Group Health Insurance (NGHP) - Liability, No-Fault and Workers Compensation

The goal behind NGHP reporting is to give CMS some of the lift to post-pay savings they achieved through the pre-pay GHP VDSA processes. NGHP reporting is conceptually the same -- insurers report cases quarterly via electronic submission, but the details of the reporting requirements are much different.  Insurers must report payment, judgment or award  that occured in the last reporting period.  If there is ongoing responsibility for paying, then the original report must be followed by an update when the obligation ends.  Updates are also required for CMS designated data elements such as updating injury information.  CMS also requires insurers to report any ongoing responsibility that existed as of 1 January 2009 in their first report.  Workers Compensation Medical Set Asides (WCMSA) are not included in MMSEA. Contact Piatt Consulting to use our web-based reporting software, or engage us to act as your reporting agent Medicare Consul Services.

GHP Small Employer Exception -- SEE

CMS regulations allow for employers with fewer than 100 and fewer than 20 full or part-time employees an exception.


There are at least two aspects to compliance: providing the required data elements and reporting in a timely and accurate fashion.  Penalties for failing to report in a timely manner are stiff: $1,000.00 per day per Medicare Beneficiary.

The Coordination of Benefits (COB) is tasked with accepting, rejecting and monitoring file submissions for timely reporting. It is unclear at the moment, how CMS may police the reporting, but consider that if the reporting is done promptly and correctly, there should be a reduction in Medicare GHP recoveries and it is anticipated that the attorney community will aggressively report NGHP liability cases.

CMS has stated that for the purposes of the reporting requirements at 42 U.S.C. 1395y(b)(7), agents may submit reports on behalf of RREs.

Reporting Agent Solution

Piatt Consulting announces Medicare Consul Services a cost-effective, one-stop reporting solution -- at a fraction of the cost of building your own system. Self-insured entities and mainstream insurers will benefit from a tiered pricing structure that provides an inexpensive solution for reporting just a few, or millions of Medicare beneficiaries.

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