SCHIP Extension Act of 2007
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On December 29, 2007, President George Bush signed into law the “Medicare Medicaid, and SCHIP Extension Act of 2007 [PDF:128KB]. The new legislation amends the Medicare Secondary Payer Act (MSPA) by establishing new reporting guidelines. Under the new rules, group health plans, liability insurers, no-fault insurers, workers’ compensation insurers and self-insurers will be required to determine whether any individual who files a claim against the insurer or any entity insured or covered by the insurer is entitled to Medicare benefits.
On August 1, 2008, CMS issued a Supporting Statement [PDF:128KB] further clarifying the reporting requirements imposed by the Act and the Secretary of Health and Human Services. Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 adds new mandatory reporting requirements for group health plan (GHP) arrangements and for liability insurance (including self-insurance), no-fault insurance, and workers' compensation for Medicare eligible claims where Medicare does not have primary responsibility for paying the medical expenses of said beneficiary. Mandatory reporting will only affect cases where the claimant/plaintiff is entitled to or receiving Medicare benefits or certain GHP beneficiaries below:
- Who are age 65 or older and working with coverage under an employer- sponsored and/or contributed to GHP, for an employer with 20 or more employees (or if it is a multi-employer plan where at least one employer has 20 or more full or part-time employees);
- Who are age 65 or older and with coverage under a working spouse’s employer-sponsored and/or contributed to GHP, for an employer with 20 or more employees (the working spouse can be any age)(or if it is a multi-employer plan where at least one employer has 20 or more full or part-time employees);
- Who have End Stage Renal Disease (ESRD) and are covered by a GHP on any basis (Medicare is secondary for a 30 month coordination period.); or
- Who are disabled and have coverage under their own or a family member’s GHP for an employer with 100 or more full or part-time (or if it is a multi-employer where at least one employer has 100 or more full or part-time employees.)
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An individual has a "reasonable expectation" of Medicare enrollment if any of the following situations apply:
- The individual has applied for Social Security Disability Benefits;
- The individual has been denied Social Security Disability Benefits but anticipates appealing that decision;
- The individual is in the process of appealing and/or re-filing for Social Security Disability Benefits;
- The individual is 62 years and 6 months old (i.e., may be eligible for Medicare based upon his/her age within 30 months); or
- The individual has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.
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CMS will require ongoing quarterly reporting for all applicable claims through an electronic process, which is being developed at this time. Reporting for contested claims which have been resolved through a single settlement, judgment, award, or other payment will only require reporting to be a one-time occurrence. Failure to comply with these federal reporting guidelines may result in a penalty of $1000 per day, per claim.
CMS will utilize this information to recover conditional payments made in GHP and non-GHP cases and to prevent conditional payments from being made in the future.
All instructions for implementation will appear at this site, through a link to this site, or as a document which may be downloaded from this site or an associated link.
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