Group health plans are facing a major new data collection challenge.
Since Jan. 1, 2009, the federal government has required the insurers and administrators for plans over a certain minimum size to give it the information it needs to determine whether some Medicare beneficiaries also have employer-sponsored health coverage.
The minimum size is 100 full-time and part-time employees for filing information about disabled employees, and 20 employees for coordinating Medicare and group plan benefits for employees who may be age 65 or older, or who may have covered spouses who are over age 65.
However, there is no minimum size at all for employers and plans responsible for filing benefits coordination information for employees with end-stage renal disease, according to Jack Rovner, a partner in the health law practice group at Neal Gerber Eisenberg L.L.P., Chicago.
Multiemployer group plans, such as union plans, made up entirely of very small employers are exempt, but, if even one of the employers has 20 or more employees, the entire multiemployer group must file the Medicare coordination information, Rovner says.
The reporting entities must submit the required information through the Web.
In practice, Rovner says, the rules will mean that health carriers and plan administrators will have to ask agents, brokers and consultants to help them get employers to come up with the names, ages and Social Security numbers of every dependent and every spouse of every plan member ages 45 and older.
Brokers and agents will “start getting pressure from the insurers they represent to make sure everyone knows they have to collect this data,” Rovner says.
Meanwhile, Medicare secondary payer rule guidance is still evolving, and it is not clear what employers and plans should do about infant dependents or foreign national spouses who do not yet have Social Security numbers, Rovner says.
During a town hall meeting held in October, CMS officials suggested plans should do what they can to get Social Security numbers or Medicare health insurance claim numbers from plan members affected by the reporting requirements, or get an affidavit from the individual stating that the individual does not have either a Social Security number or Medicare coverage.
The changes are the result of the Medicare secondary payer mandatory reporting provisions in Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007, also known as MMSEA.
Federal law always has required workers’ compensation insurance programs to pay first when Medicare and workers’ comp overlapped, according the officials who wrote the preamble to Medicare secondary payer rule amendments that appeared in the Federal Register in February.
Starting in 1980, Congress began trying to control Medicare expenditures by making Medicare the secondary payer, rather than the primary payer, in many more instances in which Medicare coverage and other types of coverage overlap.
Officials at the U.S. Government Accountability Office noted in a 2004 report that the methods Medicare officials have used to get non-Medicare plans to pay first have not worked very well.
In 2000, CMS officials believed that about 8% of Medicare beneficiaries had coverage that overlapped with Medicare, GAO officials wrote in the report.
Medicare paid about $271 billion for the care of older and disabled individuals in 2003, and other carriers were the primary payer for about $183 million of those expenditures, GAO officials wrote.
Employer-sponsored group health plans were responsible for about $134 million of that “Medicare secondary payer debt,” officials wrote.
In theory, doctors and hospitals have been responsible for policing patients’ use of overlapping coverage, but few have done so, Rovner says.
Employers, plans and government agencies had voluntary data-sharing arrangements, but “there was no formal way for government agencies or employers to figure out who was who,” Rovner says.
Although the new MMSEA rules may pose data collection challenges, they may help some group plans, by making administrators aware of group plan members for whom Medicare should be the primary payer, Rovner says.