CMS Data Match Program

CMS Data Match Program

Although the
program has been around since 2007, Centers for Medicare and Medicaid Services
(CMS) have issued a significantly greater number of notices to employers this
year expecting assistance in determining if Medicare should be primary or
secondary for specific employees, during specific time frames.  The Medicare Secondary Payer (MSP) determination
is based on total number of an employer’s employees, full-time and
part-time.  For working aged, the
employer group plan is primary if there are 20 or more employees for 20 or more
calendar weeks in the current or preceding calendar year.  If the employer has fewer than 20 employees,
Medicare is primary. 

For Medicare
eligibility due to disability, the rules change from 20 employees to 100
employees.  If the employer has fewer
than 100 employees for more than 50% of the previous calendar year’s business
days, then Medicare is primary.

Inevitably, when an employer receives
the notice to comply with the Data Match request, there is a sense of
overwhelming responsibility and time required to respond.  The communication from CMS can be
intimidating with threats of penalties for non-compliance.  Fortunately, the task is not as daunting as
it initially seems.  There are several
steps to complete the process:

  1. The
    employer needs to create an account on the CMS website.  There is a 1-2 day turnaround for CMS to
    respond and identify the specific employees in question.

  2. The
    employer logs in to the CMS site using their EIN and PIN provided in the CMS
    letter.  The employer then provides
    information about their health plan carrier, group ID, Rx BIN, PCN numbers, and
    insurance company address and EIN.

  3. The
    employer must then answer questions about specific employees that may have had
    coverage through the employer group plan in addition to Medicare.

  4. Review
    and attest the information provided is complete and accurate.

  5. Submit.

CMS can look back
5 years to review claims and services and require claims to be
reprocessed.  When CMS determines another
payer should have been primary instead of Medicare, the claim may be
significant.  The insurance company, if
the plan was fully-insured, is responsible for paying the claim.  If the plan was self-funded, the employer is
responsible for paying the claim.

The Data Match
Program has enabled CMS Trust Fund to save over 3 billion dollars to date.  Because of such success, we anticipate the
program to continue for some time.

Employers who
receive the Data Match notice have 30 days to complete the questionnaire,
unless an extension is applied for. 
Don’t hesitate to contact your Business Benefits’ representative if you
need any assistance gathering information from the insurance companies,
especially if the CMS request goes back several years!