Liability Insurance, Self-Insurance, No-Fault Insurance and Workers' Compensation (NGHP)

New Provisions For Liability Insurance (including Self-Insurance), No-Fault Insurance and Workers' Compensation, found at 42. U.S.C. 1395y(b)(8)

Section 111 adds reporting rules; it does not eliminate any existing statutory provisions or regulations.

The new provisions do not eliminate CMS' existing processes if a Medicare beneficiary (or his/her representative) wishes to obtain interim conditional payment amount information prior to a settlement, judgment, award, or other payment.

1. Who Must Report:  "an applicable plan." , "...[T]he term 'applicable plan' means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan, or arrangement: (i) Liability insurance (including self-insurance). (ii) No fault insurance. (iii) workers' compensation laws or plans."
   • It includes penalties for noncompliance.
2. What Must Be Reported:  The identity of a Medicare beneficiary whose illness, injury, incident, or accident was at issue as well as such other information specified by the Secretary to enable an appropriate determination concerning coordination of benefits, including any applicable recovery claim.
   • Data elements determined by the Secretary.
3. When/How Reporting Must be Done:
   • In a form and manner, including frequency, specified by the Secretary.
   • Information shall be submitted within a time specified by the Secretary after the claim is resolved through a settlement, judgment, award, or other payment (regardless of whether or not there is a determination or admission of liability).
   • Submissions will be in an electronic format. 
4. Use of Agents: The applicable NGHP RRE may contract with an entity to act as an agent for reporting purposes. Agents may include, but are not limited to, data service companies, consulting companies or similar entities that can create and submit Section 111 files to the COBC on behalf of the RRE. An RRE may not shift its Section 111 reporting responsibility to an agent, by contract or otherwise.  The RRE remains solely responsible and accountable for complying with CMS instructions for implementing Section 111 and for the accuracy of data submitted.