Ongoing Responsibility for Medicals

Under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of 2007, applicable plans, like liability insurance, including self-insurance, no-fault insurance, and workers’ compensation (WC) laws or plans, are required to report settlements, judgments, awards, or other payments involving people who are or were Medicare patients to CMS. These applicable plans are referred to as Responsible Reporting Entities (RREs).

What to report

This required reporting includes situations where the RRE has assumed ongoing responsibility for medicals (ORM) related to specified medical conditions. CMS uses this information to determine the primary payer for claims.

Examples of ORM include:

• A no-fault insurer agrees to pay submitted medical bills until the policy is exhausted
• A WC plan is required by state law to cover medical costs until there’s a formal decision on a pending WC claim

Partial responsibility

An RRE may assume responsibility for ORM for 1 or more alleged injuries or illnesses without assuming ORM for all alleged injuries or illnesses in a claim. For example, if a person alleges both a broken leg and a back injury, the RRE might accept ORM for the broken leg while continuing to dispute the back injury.

When it ends

When a policy limit is reached or a settlement ends the RRE’s responsibility for ongoing medical payments, the RRE must report an ORM Termination Date. The Benefits Coordination & Recovery Center (BCRC) uploads termination information to the Common Working File (CWF).

Review Change Request 8984 for ORM policies, processes, and procedures.