Physical trauma-based NGHP reporting threshold remains at $750 in 2019

As required by section 1862(b) of the Social Security Act, the Centers for Medicare and Medicaid Services (CMS) has reviewed the costs related to collecting Medicare’s conditional payments and compared this to recovery amounts. The full report, released November 15, 2018, is available here. As a result of the computation, the threshold for physical trauma-based liability insurance settlements will remain at $750 in 2019.

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Despite settlement agreement, primary payer receives request for reimbursement

On August 6, 2018, in the United States District Court for the District of South Carolina, Florence Division, Humana Insurance Company (Humana) brought an action against Bi-Lo, LLC (Defendant), a Delaware limited liability company that sells groceries in the southeastern region of the United States. Humana’s action is for declaratory judgment to recover double damages pursuant the Medicare Secondary Payer Act (MSP) in the amount of $32,754.02 due and owing to Humana, as a Medicare Advantage Organization (MAO), by virtue of payments made on behalf of one of its enrollees, a Medicare beneficiary who elected Medicare Advantage coverage from Humana. This occurred despite the existence of a settlement agreement in which the enrollee and her counsel agreed to be responsible for such reimbursement. However, because the enrollee/counsel did not reimburse the Medicare payments advanced by Humana, Humana again seeks reimbursement from the Corporate Defendant.

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MAP and PDP Private Cause of Action Suits Not Just a Fad

If you are keeping up with Medicare Secondary Payer (MSP) trends and updates, then you know that Medicare Advantage Plans (MAPs) and Prescription Drug Plans (PDPs) private cause of action suits continue to be the rage, with case law arising in federal district and circuit courts across the country. When you add the recent announcement from the Centers for Medicare & Medicaid Services (CMS) that Medicare Advantage premiums will decline while plan choices and new benefits increase, it’s no wonder enrollment is projected to reach a new all-time high with more than 36 percent of Medicare beneficiaries expected to be enrolled in Medicare Advantage in 2019. With more Medicare beneficiaries switching from Medicare Parts A and B traditional coverage to Part C Medicare Advantage coverage, more and more of these MAPs will be providing your insured, and therefore your potential claimants, with Medicare benefits related to your claim. So, if you thought MAP and PDPs’ Medicare Secondary Payer private causes of action were a fad, think again.

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Trends affecting Workers’ Compensation Medicare Set-Aside Allocations

Capitol Bridge, LLC, the newest Workers’ Compensation Review Contractor (WCRC) for the Centers for Medicare and Medicaid Services (CMS), officially took over on March 19, 2018. Since that time, the Medicare Set-Aside (MSA) industry has noticed aggressive changes in the Workers’ Compensation Medicare Set-Aside (WCMSA) review process, resulting in an increase in WCMSA allocations. At … Read moreTrends affecting Workers’ Compensation Medicare Set-Aside Allocations