Medicare Part C & D Conditional Payments Update: Enactment of the Provide Accurate Information Directly (PAID) Act

2.3.2021 Blog

Medicare coverage is not limited to Medicare Part A (Hospital Insurance) and Part B (Medical Insurance). Medicare Advantage Plans (Part C) are also an available option for Medicare beneficiaries.  Part C Plans have significantly increased in popularity in recent years. Currently, as least one third of all Medicare beneficiaries are enrolled in a Medicare Part C Plan. Prescription drug coverage is also available through a Medicare Part D plan or as part of a Medicare Part C Plan. Each year during the Medicare enrollment period, beneficiaries have the right to choose Medicare coverage for the following year. As a result of the annual enrollment choice afforded Medicare beneficiaries, a Medicare beneficiary may have been enrolled in multiple Medicare plans during the pendency of a claim.

Currently, in response to a proper Section 111 inquiry, the Centers for Medicare and Medicaid Services (“CMS”) only confirms whether a claimant is enrolled in Medicare. CMS does not identify the type of Medicare program in which a claimant is enrolled. CMS only tracks Medicare Part A and Medicare Part B payments (original Medicare). If a claimant is not enrolled in original Medicare, it has been a challenge for primary payers to identify what Medicare Part C Plan(s) and/or Medicare Part D Plan(s) a claimant has been enrolled in during the pendency of a claim. Meanwhile, several Medicare Part C Plans have aggressively pursued reimbursement from primary payers under the private cause of action provision of the Medicare Secondary Payer Act, which provides for double damages. The absence of access to information on the Medicare plans enrolled in by a claimant during the pendency of a claim has been frustrating, challenging, and costly for primary payers.

On December 11, 2020, a big step was taken to remedy this situation with the enactment of the Provide Accurate Information Directly (PAID) Act. The PAID Act requires CMS expand its Section 111 query process to identify whether a claimant is, or during the preceding three years, has been entitled to Medicare Part C and/or Medicare Part D prescription drug benefits and to provide the names and addresses of such Plans. The deadline for implementation of the PAID Act requirements is December 11, 2021. Once implemented, the information provided by CMS under the PAID Act will provide primary payers with the necessary information to address potential Part C and/or Part D recovery claims for treatment during the preceding three years which should reduce primary payer exposure to a private cause of action seeking double damages. For those claims that are older than the three preceding years, methods used to identify Part C and/or Part D Plan(s) should continue.

This addition will also mean a change to primary payers’ Medicare queries. Currently, most payers query until a beneficiary becomes Medicare entitled then, once they report ongoing responsibility for medical treatment (ORM), the payer stops querying.  Since only the query will yield a Medicare beneficiary’s Part C and/or D plan information, payers will need to query Medicare beneficiaries at least every three years, and more likely annually, to ensure they capture the contact information for each applicable Medicare plan during the pendency of a claim.  Since the Medicare query does cost money for those payers using a vendor for their Section 111 reporting, this will be an additional expense to the claim.

Another issue to consider is that the Claimant’s attorney does not have access to the Section 111 query function, and therefore, only the primary payer will have access to all historic Medicare entitlement information.  Also, primary payers using separate companies for conditional payment negotiation and Section 111 reporting will need to ensure the data flows smoothly from their reporting company to their conditional payment vendor so all plans’ recovery claims are addressed before settlement.

Our team of credentialed and experienced MSP attorneys is available to help insurers and employers navigate conditional payment challenges including those involving Medicare Part C and Medicare Part D plans.  If you ever have questions, please feel free to reach out.

The NBKL blog is provided for informational purposes; we are not giving legal advice or creating an attorney/client relationship by providing this information.  Before relying on any legal information of a general nature, you may consider consulting legal counsel as to your particular facts and applications of the law.