Updated MMSEA User Guide, Version 4.5
Jeff Signor
February 3, 2015

CMS released this morning another update to the MMSEA User Guide, version 4.5.

The link to the new User Guide can be found here:

http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/NGHP-User-Guide/NGHP-User-Guide.html

The purpose of the release was to integrate into the User Guide, at Chapter 3, CMS rules regarding the reporting of losses involving implantation, exposure and ingestion.  These rules were clarified last year by Policy and covers when a RRE is required to report data regarding such losses as it may involve issues that pre-date the MSP law. Section 6.5 of Chapter 3 covers the issue.

In summary, a RRE is NOT required to report data when ALL of the following conditions are met:

  • All exposure or ingestion ended, or the implant was removed before 12/5/1980; and, Exposure, ingestion, or an implant on or after 12/5/1980 has not been claimed and/or specifically released; and
  • There is either no release for the exposure, ingestion, or an implant on or after 12/5/1980; or where there is such a release, it is a broad general release (rather than a specific release), which effectively releases exposure or ingestion on or after 12/5/1980. 

The rule also applies if the broad general release involves an implant.

Franco Signor continues to monitor releases and updates by CMS to the MMSEA User Guide as well as other CMS policies applicable to general MSP compliance requirements.  This update clarifies when a RRE should report as well as when Medicare will assert a recovery.  What is not covered is how mass tort claims, which typically involves ingestion, implantation and exposure losses, are to be handled for reporting purposes.  It would appear the current “stay” on reporting is still in place for those claims, however, this recent release, without comment, would encourage RREs to report to the extent such claimants are identified.