CMS Implements PAID Act for NGHP Medicare Secondary Payer Compliance and More!

We recently wrote about the April 1st Benefits Coordination & Recovery Center (BCRC) and Commercial Repayment Center (CRC) Non-Group Health Plan (NGHP) Town Hall in which both Medicare recovery entities defined their specific responsibilities and clarified some leading industry questions regarding MMSEA Section 111 reporting and the recovery centers.

In follow up, CMS announced on June 8, 2021, an Updated MMSEA Section 111 Non-Group Health Plan (NGHP) User Guide and NGHP 270/271 Health Care Enrollment Benefit Inquiry and Response Companion Guides made available on June 11, 2021.

What are the Changes in this Release?

The following will become effective December 11, 2021:

The Provide Accurate Information Directly Act (PAID Act) was passed in 2020 to help NGHP Responsible Reporting Entities (RREs) by providing beneficiary enrollment information for Medicare Part C Medicare Advantage Plans and Medicare Part D Prescription Drugs. As a result, RREs will receive Medicare Advantage Plan and Medicare prescription drug coverage enrollment information, as well as the most recent Medicare Part A (Hospital) and Part B (Outpatient) entitlement dates, for the past 3 years.

Technically, the CMS’ HIPAA Enrollment Wrapper (HEW) software will be updated and the X12 271 query formats will be modified to extract the additional fields (see 271 Enrollment Response Companion Document).

For clarity, CMS describes the X12 270/ 271 Companion Guide as follows:

Section 111 NGHP RREs have the ability to transmit a query file to request information regarding the Medicare status of injured parties to help determine whether liability insurance, no-fault insurance or workers’ compensation claim information should be reported. This query file is submitted in the form of an ANSI X12 270/271 Health Care Enrollment Benefit Inquiry and Response transaction set. If you choose to use your own ANSI X12 translator to create the X12 270 files for the Section 111 Query File and process the X12 271 response, please refer to the Companion Guide which is available in the Downloads section below. This is to be used in conjunction with the National Electronic Data Interchange Transaction Set Implementation Guide and the Health Care Enrollment Benefit Inquiry and Response, ASC X12N 270/271 Implementation Guide. Please refer to the Query Input and Response File requirements in the NGHP User Guide for more information.”

This is an exciting development as this change will eliminate much of the delay in obtaining Medicare Advantage and Medicare Prescription Drug plan enrollment information, by allowing access to this information within the MMSEA Section 111 reporting file. To access this information, you must have access to the reporting data in the response file.

As mentioned in a prior blog, Care Bridge International has immediate electronic access to enrollment details, and has been providing this very enrollment information to our clients for the past 4 years! Expect your MMSEA Section 111 Agent to receive this information electronically in early 2022.

With a Medicare Beneficiary ID (MBI) number, a detailed enrollment report is immediately provided to you, by Care Bridge International, with complete details including all date(s) of enrollment (not limited to 3 years), plan changes/ updates, the plan name, address, phone number, policy number and any corrections to the legal name, date of birth, or gender, which may be in error on your claim file. If the date of injury on your claim is greater than 3 years, you will still be remiss in obtaining critical enrollment information that impacts your Medicare Secondary Payer responsibility for resolving conditional payments, payments made by CMS on behalf of an accident/ injury claim where a primary payer exists. This limitation will pose a problem for older claims, and we are available to help you obtain this necessary and accurate information now.

Reporting agents must begin to prepare today for these changes!