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CMS Proposes Methods to Calculate Civil Monetary Penalties for Group, Non-group Plans

Medicare

WASHINGTON, D.C. — The Centers for Medicare & Medicaid Services (CMS) has proposed methods to calculate and impose civil money penalties (CMPs) when a group health plan (GHP) or a non‑group health plan (NGHP) entity fails to comply with Medicare Secondary Payer (MSP) reporting requirements.

The proposed rule defines circumstances when a CMP may or may not be imposed, and updates all related regulatory text.

Under provisions of this proposed rule, CMS will continue its efforts to safeguard patients and taxpayers by reducing their risk of inappropriate claims, minimizing healthcare benefit denials and protecting federal funding with clear guidance and better coordination.

This proposed rule will ensure that the appropriate insurers are compliant with their reporting requirements and primary payment responsibilities for healthcare services covered by their healthcare coverage programs.  A 60-day public comment period seeks feedback on the proposals.

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Statutory Requirements

  • Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (commonly referred to as “Section 111 reporting”) added mandatory reporting requirements for GHP and NGHP entities by adding Section 1862(b)(7) and (b)(8) of the Social Security Act (“the Act”).
  • Section 1862(b)(7) and (b)(8) of the Act also specify civil money penalties for entities that fail to comply with these reporting requirements, of $1,000 per day per individual for GHPs and up to $1,000 per day per claimant for NGHP entities.
  • The Medicare IVIG Access and Strengthening Medicare and Repaying Taxpayers Act of 2012,” (also called “the SMART Act”) amended the existing enforcement provisions to state that an NGHP failing to comply with reporting requirements may be subject to a CMP of up to $1,000 for each day of noncompliance for each claimant. GHPs with reporting obligations remain subject to mandatory CMPs of $1,000 per day of noncompliance per individual.  CMS’ proposed CMPs would be levied in addition to any MSP reimbursement obligations.
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