MSA News - Centers for Medicare and Medicaid Services (CMS) Issues Final Rule for Medicare Secondary Payer Determinations

On 2/27/15, CMS issued its final rule implementing provisions of the Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act) which require them to provide a right of appeal and an appeal process for liability insurance (including self-insurance), no-fault insurance, and workers' compensation laws or plans.

For background on this subject, Congress enacted the Medicare Secondary Payer (MSP) provisions of the Social Security Act (the Act) in 1980, which added section 1862(b) to the Act and established Medicare as the secondary payer to certain primary plans. Primary plan, as defined in section 1862(b)(2)(A) of the Act, means a group health plan or large group health plan, workers' compensation law or plan, automobile or liability insurance policy or plan (including self-insured plan) or no-fault insurance.

Subsequently, the Strengthening Medicare and Repaying Taxpayers Act of 2012 (the SMART Act) was signed into law by President Obama on January 10, 2013, and amends the Act's MSP provisions (found at 42 U.S.C. 1395y(b)). Specifically, section 201 of the SMART Act added paragraph (viii) to section 1862(b)(2)(B) of the Act. This new clause requires Medicare to promulgate regulations establishing a right of appeal and an appeals process, with respect to any determination for which the Secretary of Health and Human Services is seeking to recover payments from an applicable plan (as defined in the MSP provisions), under which the applicable plan involved, or an attorney, agent, or third-party administrator on behalf of the applicable plan, may appeal such a determination. Further, the individual furnished such an item and/or service shall be notified of the applicable plan's intent to appeal such a determination.

For more information about the details of the Final Rule, please click here >>