Rafael Gonzalez, Esq.

Settling a case with a current Medicare beneficiary for more than $750? As of April 4, 2025, in addition to all of the previously required data points to be reported to Medicare, the payor must now also report the amount to be allocated for future medical care and treatment out of the agreed upon and/or approved settlement. In order to assist both employer/carrier and Medicare beneficiaries fulfill and comply with this latest mandate, Cattie & Gonzalez, the country’s premiere law firm focusing its entire practice on Medicare, Medicaid, ERISA, and Military secondary payer issues, is now offering its Medicare Set Aside Mandatory Insurer Reporting Legal Opinion (MSA MIR Legal Opinion).

MMSEA Section 111 Reporting

To ensure that Medicare was informed of settlements and had the opportunity to exert any reimbursement obligation it believed it was entitled to, Congress passed the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) which implemented requirements for insurance carriers and self-insured defendants to report to Medicare when they accepted responsibility for and settled a claim with a Medicare beneficiary. This would allow Medicare to establish a conditional payment record of recovery if one was not already established by the parties themselves prior to resolving the claim. In the process of reporting, responsible reporting entities (RREs) must report certain data points to Medicare to identify any available primary payer of medical expenses before Medicare as well as document the settlement details and begin its recovery actions. 

Any liability insurance (including self-insurance), no fault-insurance, or workers’ compensation insurance claim that is resolved with a settlement, judgment, payment or other award is required to report certain data points to Medicare under the MMSEA Section 111 obligations (Section 111 Reporting). However, such reporting is only required if the claim meets the two (2) following thresholds: 

1. The claimant has been identified as a current Medicare beneficiary; and 

2. The total payment obligation to claimant (TPOC) exceeds Medicare’s reporting threshold, currently at $750.00. 

If an RRE is resolving a claim with a current Medicare beneficiary, and the settlement is over $750, the RRE would be responsible for reporting the following data points to Medicare: 

·  The claimant’s identity, including Social Security Number or Medicare ID, the first six (6) letters of their first name, the first six (6) letters of their last name, their date of birth, and their gender; 

·  The RRE’s Taxpayer Identification Number (TIN); 

·  The RRE’s address information;

·  Ongoing responsibility for medicals (ORM) in either the affirmative or the negative; and 

·  The TPOC, including the dollar amount of a settlement, judgment, award, or other payment; the date that the payment obligation was established (such as the final date of settlement or court approval of a settlement if applicable, etc.). 

Reporting Work Comp MSA Data Points

When Congress enacted and President Bush signed into law Medicare’s Mandatory Insurer Reporting law at 42 USC 1395y(b)(8) in 2007, Congress provided the Secretary of the Department of Health and Human Services (HHS) the authority to require “such information as the Secretary shall specify in order to enable the Secretary to make an appropriate determination concerning coordination of benefits, including any applicable recovery claim.” 

Pursuant to this authority, and based on the statutorily indicated need, beginning April 4, 2025, Medicare will begin to also require reporting of additional data points specific to WCMSA information via Section 111. Considering the decrease in the number of WCMSAs voluntarily submitted to CMS for review and approval, and the increase in use of non-submit WCMSAs, this change was made so that Medicare could gather MSA information even when parties did not take advantage of the voluntary MSA submission and approval process Medicare established or when a settlement failed to meet the review threshold for parties to take advantage of that submission process. 

The data points specific to WCMSA information required as of April 4, 2025 (the “MSA-specific Data Points”) includes the following: 

·  MSA Amount – the total MSA being established as a result of the settlement; 

·  MSA Period – the number of years the WCMSA is designed to cover medical expenses for the beneficiary; 

·  Lump Sum or Structured/Annuity Payout Indicator – whether the WMCSA will be financed with a lump sum deposit of the full value of the WCMSA or an annuity (or other structure) will be used to fund it over time; 

·  Initial Deposit Amount – the value to be initially deposited into the WCMSA upon establishment if the WCMSA will be funded with an annuity (or other structure) to fund it over time as opposed to a lump sum deposit of the full value of the WCMSA; and 

·  Anniversary Deposit Amount – the amount to be deposited into a WCMSA on an annual basis when the WCMSA is funded with an annuity (or other structure). 

Additionally, there are two data points that are optional to include in the reporting: 

·  Case Control Number – when an MSA proposal has been submitted to Medicare for its review and approval and has been assigned a Case Control Number, that identifying number may be reported; and 

·  Professional Administration EIN – when the WCMSA is professionally administered (as opposed to self-administered by the beneficiary or their representative), that entity’s tax ID number may be reported.

The Cattie & Gonzalez MSA MIR Legal Opinion

Based on this latest requirement, there are two issues that must be immediately addressed in order for an RRE to be compliant and for a Medicare beneficiary to be certain his/her future Medicare coverage is protected: 

Issue #1 = Are the parties required to submit MSA-specific data points to Medicare as a part of resolving the workers compensation claim? 

Issue #2 – If yes to Issue #1, then what amount should the parties consider allocated to future medical expenses within the settlement and report to Medicare under the MMSEA Section 111 reporting obligations? 

For obvious competitive and legal reasons, I will not provide the details of our analysis here. But, in answering both of these issues, and in order to be legally compliant and appropriately consider and take Medicare’s future interests into consideration, on each case, our MSA MIR Legal Opinion will provide a detailed breakdown of the following factors and will derive at a case specific, legally sound, four step determined allocation amount, ending with our legal conclusion for purposes of MSA reporting fields and data points:

·  Verification of Medicare Entitlement.

·  A Review of the Medicare Secondary Payer Statute.

·  Statutory Obligation Analysis.

·  Future Medical Allocation Analysis.

·  MSP Act Determined Allocation Amount 

·  Conclusion for MSA Reporting Fields and Data Points

And of course, as with every legal opinion our firm provides, clients hiring Cattie & Gonzalez for an MSA MIR Legal Opinion enjoy the benefits of having the law firm stand behind its conclusions.  If Medicare were to disagree with the MSA amount we recommended as part of the MSA MIR Legal Opinion, Cattie & Gonzalez will challenge Medicare as to its conclusions and follow the allowed administrative appeal processes to support its conclusions on behalf of the client at no additional cost to the client. In addition, if Medicare demands repayment of any post-settlement conditional payments arising from our client’s reliance on our MSA MIR Legal Opinion, Cattie & Gonzalez will also defend its opinion, directly with Medicare, and follow the allowed administrative appeal processes to support its conclusions on behalf of the client at no additional cost to the client.  

To speak with us about any of our Medicare, Medicaid, ERISA, or Military secondary payer legal products and services, including our MSA MIR Legal Opinion, please visit us at www.cattielaw.com, reach out at info@cattielaw.com, or call us at 844.546.3500.