U.S. House Bill Requires CMS to Disclose Beneficiaries' Enrollment Status in Private Medicare Parts C & D and Medicaid

Nationwide reimbursement litigation by private Medicare Advantage Plans (MAPs) providing health coverage to some Medicare enrollees has grown significantly over the past few years. Any number of entities are sued for failing to reimburse MAPs for injury-related treatment costs when a beneficiary is paid to resolve a claim. These include alleged tortfeasors, their insurers, tort plaintiffs, and their attorneys. Determining if a claimant receives health coverage under Medicare that paid a claimant’s medical expenses related to an injury is critical to complete claim resolution. For enrollees in government Medicare, Parts A and B, this is a relatively straightforward process. The Centers for Medicare & Medicaid Services (CMS) implemented a query process where this enrollment status can be verified. However, this query system only reports on a limited basis one’s enrollment status in private Medicare, Parts C (MAPs) and D (prescription drugs), or Medicare. Primary payers’ reimbursement efforts are hamstrung by the inability to confirm with CMS a beneficiary’s enrollment status in all Parts of Medicare or Medicaid.

Enactment of Medicare Part C in 1997 and Medicare Part D in 2003 created new, unique secondary payer issues. Legislation introduced May 18 in the U.S. House would require CMS to report one’s enrollment status in all Parts of Medicare, and Medicaid also. Additionally, it requires disclosure of the identities of particular Medicare Advantage and prescription drug plans in which a beneficiary is enrolled. The bill is entitled the “Provide Accurate Information Directly Act”; the “PAID Act” for short (H.R. 5881, 115th Congress (2017-2018)). Its bipartisan sponsors are Reps. Gus Bilirakis [R-FL-12], Dennis Ross [R-FL-15], and Ron Kind [D-WI-3]. Their stated purpose for the bill is to amend Title XVIII of the Social Security Act to provide transparency of Medicare secondary payer reporting information. It was referred for consideration to the Committees on Ways and Means and on Energy and Commerce for a period to be determined by the Speaker.

In a press release issued May 21, Rep. Bilirakis describes the bill. He stated,

“[t]he inability to obtain basic information about MSP [Medicare Secondary Payer] liabilities hinders participants’ ability to retain access to proper care and quickly resolve medical liability settlements. This legislation will ensure that beneficiaries, Medicare, and Medicaid have a clear and quick way to identify whether or not a participant has an MSP obligation, and provide information about how that obligation can be resolved. The PAID Act represents a ‘win-win-win’ for beneficiaries, plans, and the federal taxpayer.”

This press release also quotes Rep. Kind. He stated,

“Congress can save significant money for taxpayers and drive a better coordination of benefits if it mandates the sharing of certain information between CMS and settling parties. If settling parties are simply provided with basic plan information, they will be able to quickly repay liabilities associated with settlements, judgments, or awards.”

This bill represents a major step in Medicare reform. If enacted, it will timely provide valuable information to help determine if private Medicare providers or Medicaid have secondary payer rights. Primary payers will have access to this enrollment data prior to payment of claim resolution proceeds. They can then better avoid the double damages reimbursement suits by MAPs under the MSP private cause of action that have proliferated recently.

  • Sean P. Sheehan

    Sean P. Sheehan focuses his practice on trials involving complex litigation matters, including toxic torts, personal injury, wrongful death, and asbestos products, premises, supplier, distributor, contractor, and employer ...

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Kerri Forsythe

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