CMS Issues Proposal Establishing Appeal Process for Applicable Plans in Medicare Secondary Payer Cases


On December 27, 2013, CMS issued proposed changes to the regulation governing Medicare Secondary Payers (MSP) to establish a formal, multilevel administrative appeals process for applicable plans against which MSP recovery demands are issued.  Comments must be received no later than February 25, 2014 at 5 p.m. 

The Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act), enacted January 10, 2013, requires the right of appeal and an accompanying process for liability insurance (including self-insurance), no-fault insurance, and workers’ compensation laws or plans when Medicare pursues a MSP recovery claim directly from such laws or plans.  The proposed rule, among other things, defines “applicable plans” that may be party to the appeal process, explains what constitutes notice of an initial determination for appeal purposes, and sets forth requirements of notice to a beneficiary if an applicable plan requests a redetermination. 

Reporter, Paige Fillingame, Houston, +1 713 615 7632,

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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