[Federal Register Volume 78, Number 249 (Friday, December 27, 2013)]
[Proposed Rules]
[Pages 78802-78807]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2013-30661]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 405
[CMS-6055-P]
RIN 0938-AS03
Medicare Program; Right of Appeal for Medicare Secondary Payer
Determination Relating to Liability Insurance (Including Self-
Insurance), No Fault Insurance, and Workers' Compensation Laws and
Plans
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule would implement provisions of the
Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act)
which require us to provide a right of appeal and an appeal process for
liability insurance (including self-insurance), no-fault insurance, and
workers' compensation laws or plans when Medicare pursues a Medicare
Secondary Payer (MSP) recovery claim directly from the liability
insurance (including self-insurance), no fault insurance, or workers'
compensation law or plan.
DATES: To be assured consideration, comments must be received at one of
the addresses provided, no later than 5 p.m. on February 25, 2014.
ADDRESSES: In commenting, please refer to file code CMS-6055-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed).
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the instructions under
the ``More Search Options'' tab.
2. By regular mail. You may mail written comments to the following
address only:
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, Attention: CMS-6055-P, P.O. Box 8013, Baltimore, MD
21244-8013.
[[Page 78803]]
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address only:
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, Attention: CMS-6055-P, Mail Stop C4-26-05, 7500
Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. For delivery in Washington, DC--
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, Room 445-G, Hubert H. Humphrey Building, 200
Independence Avenue SW., Washington, DC 20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850
If you intend to deliver your comments to the Baltimore address,
please call telephone number (410) 786-1066 in advance to schedule your
arrival with one of our staff members.
Comments erroneously mailed to the addresses indicated as
appropriate for hand or courier delivery may be delayed and received
after the comment period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Barbara Wright, (410) 786-4292.
Cynthia Ginsburg, (410) 786-2579.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will be also available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, MD 21244-1850, Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
please phone 1-800-743-3951.
I. Overview and Background
A. Overview
When the Medicare program was enacted in 1965, Medicare was the
primary payer for all medically necessary covered and otherwise
reimbursable items and services, with the exception of those items and
services covered and payable by workers' compensation. In 1980, the
Congress enacted the Medicare Secondary Payer (MSP) provisions of the
Social Security Act (the Act), which added section 1862(b) to the Act
and established Medicare as the secondary payer to certain primary
plans. Primary plan, as defined in section 1862(b)(2)(A) of the Act,
means a group health plan or large group health plan, workers'
compensation law or plan, automobile or liability insurance policy or
plan (including self-insured plan) or no fault insurance.
Section 1862(b)(2) of the Act, in part, prohibits Medicare from
making payment where payment has been made or can reasonably be
expected to be made by a primary plan. If payment has not been made or
cannot reasonably be expected to be made by a primary plan, Medicare
may make conditional payments with the expectation that the payments
will be reimbursed to the appropriate Medicare Trust Fund. That is,
Medicare may pay for medical claims with the expectation that it will
be repaid if the beneficiary obtains a settlement, judgment, award, or
other payment (hereafter referred to as ``settlement''). Section
1862(b)(2)(B) of the Act provides authority for Medicare to make
conditional payments and requires the primary plan, if it is
responsible for the payment, to reimburse Medicare. A primary plan and
any entity that receives payment from a primary plan shall reimburse
the appropriate Medicare Trust Fund for Medicare's payments for items
and services if it is demonstrated that such primary plan has or had
responsibility to make payment with respect to such items and services.
The responsibility for payment on the part of workers'
compensation, liability insurance (including self-insurance), and no-
fault insurance is generally demonstrated by ``settlements.'' When a
``settlement'' occurs, the ``settlement'' is subject to the Act's MSP
provisions because a ``payment has been made'' with respect to medical
care of a beneficiary related to that ``settlement.'' Section
1862(b)(2)(B)(iv) of the Act provides the Federal government
subrogation rights to any right under MSP of an individual or any other
entity to payment for items or services under a primary plan, to the
extent Medicare payments were made for such medical items and services.
Moreover, section 1862(b)(2)(B)(iii) of the Act provides the Federal
government a direct right of action to recover conditional payments
made by Medicare. This direct right of action, which is separate and
independent from Medicare's statutory subrogation rights, may be
brought to recover conditional payments against any or all entities
that are or were responsible for making payment for the items and
services under a primary plan. Under the direct right of action, the
Federal government may also recover from any entity that has received
payment from a primary plan or the proceeds of a primary plan's payment
to any entity.
B. Background
The Strengthening Medicare and Repaying Taxpayers Act of 2012 (the
SMART Act) was signed into law by President Obama on January 10, 2013,
and amends the Act's MSP provisions (found at 42 U.S.C. 1395y(b)).
Specifically, section 201 of the SMART Act added subparagraph (viii) to
section 1862(b)(2)(B) of the Social Security Act. This new clause
requires Medicare to promulgate regulations establishing a right of
appeal and an appeals process, with respect to any determination for
which the Secretary is seeking to recover payments from an applicable
plan (as defined in the MSP provisions), under which the applicable
plan involved, or an attorney, agent, or third-party administrator on
behalf of the applicable plan, may appeal such a determination.
Further, the individual furnished such an item and/or service shall be
notified of the applicable plan's intent to appeal such a
determination. For purposes of this provision, the term applicable plan
refers to liability insurance (including self-insurance), no-fault
insurance, or a workers' compensation law or plan as defined at section
1862(b)(8)(F) of the Act. (We note that the industry has expressed
interest in an appeal process for determinations regarding proposed
Workers' Compensation Medicare Set-
[[Page 78804]]
Aside Arrangement (WCMSA) amounts. This proposed rule does not address
this issue. It will be addressed separately.)
Currently, if an MSP recovery demand is issued to the beneficiary
as the identified debtor, the beneficiary has formal administrative
appeal rights and eventual judicial review as set forth in subpart I of
part 405. If the recovery demand is issued to the applicable plan as
the identified debtor, currently the applicable plan has no formal
administrative appeal rights or judicial review. CMS' recovery
contractor addresses any dispute raised by the applicable plan, but
there is no multilevel formal appeal process.
Subpart I of part 405, provides for a multilevel process including
a redetermination by the contractor issuing the recovery demand, a
reconsideration by a Qualified Independent Contractor (QIC), an
Administrative Law Judge (ALJ) hearing, a review by the Departmental
Appeals Board's (DAB) Medicare Appeals Council (MAC), and eventual
judicial review. The regulations set forth details on the process
including filing requirements, amount in controversy requirements, and
other requirements, as appropriate. We propose to include appeals for
applicable plans where Medicare is pursuing recovery directly from the
applicable plan in this process. The debts at issue involve recovery of
the same conditional payments that would be at issue if recovery were
directed at the beneficiary. Given this, we believe it is appropriate
to utilize the same multilevel appeals process for applicable plans.
II. Provisions of the Proposed Regulations
After review of the existing regulations in subpart I of 42 CFR
Part 405, we are proposing the following changes, as appropriate, in
order to include the applicable plan as a party when we pursue recovery
directly from the applicable plan.
We propose to amend Sec. 405.900, Basis and Scope, by revising
paragraph (a) to add section 1862(b)(2)(B)(viii) of the Act as part of
the statutory basis for Subpart I. Section 1862(b)(2)(B)(viii) of the
Act requires an appeals process for applicable plans when Medicare
pursues recovery directly from the applicable plan.
In Sec. 405.902, Definitions, we propose to add a definition of
the term ``applicable plan'' for purposes of Subpart I. We would adopt
the statutory definition of ``applicable plan'' in section
1862(b)(8)(F) of the Act, which states that an applicable plan means
liability insurance (including self-insurance), no-fault insurance, or
a workers' compensation law or plan.
We propose to amend Sec. 405.906, Parties to initial
determinations, redeterminations, reconsiderations, hearings and
reviews by adding Sec. 405.906(a)(4) to include the applicable plan as
a party for an initial determination where Medicare is pursuing
recovery directly from the applicable plan. By ``pursuing recovery
directly from the applicable plan,'' we mean that the applicable plan
would be the identified debtor, with a recovery demand letter requiring
repayment issued to the applicable plan (or its agent or
representative). Sending an applicable plan a courtesy copy of a
recovery demand letter issued to a beneficiary does not qualify as
``pursuing recovery directly from the applicable plan'' and does not
confer party status on the applicable plan. We are also proposing a
technical change in the section heading for Sec. 405.906 (adding a
comma before the phrase ``and reviews'').
Based upon this proposed change to Sec. 405.906, the applicable
plan's party status would continue at subsequent levels of appeal.
Consistent with section 1862(b)(2)(B)(viii) of the Act, the
beneficiary, provider, and/or supplier are not considered parties to an
appeal by an applicable plan. Thus, we propose to remove the
beneficiary, as well as the provider or supplier, as a party at the
redetermination level where Medicare is pursuing recovery directly from
the applicable plan. This would also, in effect, remove the beneficiary
and the provider or supplier as a party at subsequent levels of appeal
where Medicare is pursuing recovery directly from the applicable plan.
To implement our proposed changes, we would revise Sec. 405.906 (a) to
specify: (1) The circumstances under which an applicable plan is a
party to an initial determination; and (2) when an applicable plan is a
party to an initial determination, it is the sole party with respect to
that determination. Finally, as providers and suppliers would
specifically be excluded from party status for an initial determination
with respect to an applicable plan, we would make it clear that the
special rule for provider or supplier party status in Sec. 405.906(c)
does not apply to an initial determination with respect to an
applicable plan.
In proposed Sec. 405.910, Appointed representatives, we would add
a new paragraph (e)(4) to provide the applicable plan with parallel
rights to a beneficiary's rights or a provider or supplier's rights
regarding the duration of an appointment of representation with respect
to an MSP recovery claim. We also propose to revise Sec. 405.910(i)(4)
so that the special provision that beneficiaries as well as their
representatives must receive notices or requests in a MSP recovery case
continues to apply only to beneficiaries. For all other parties,
including an applicable plan, we would continue to follow the
regulatory provisions in Sec. 405.910(i)(1) through (3).
In Sec. 405.921, Notice of initial determination, we propose to
add a paragraph (c) to provide specific language regarding requirements
for notice to an applicable plan. This language would parallel the
existing language in this section regarding the notice to
beneficiaries. In addition to these changes, for consistency we have
made a number of technical and formatting changes.
In order for an action to be subject to the appeal process set
forth in subpart I of 42 CFR Part 405, there must be an ``initial
determination.'' We propose, in Sec. 405.924, Actions that are initial
determinations, to add a new paragraph Sec. 405.924(b)(15) providing
that a determination that Medicare has a recovery claim where Medicare
is pursuing recovery directly from an applicable plan is an initial
determination with respect to the amount of or existence of the MSP
recovery claim. This addition would generally parallel the existing
provisions in Sec. 405.924(b)(14) addressing pursuing MSP recovery
claims from a beneficiary, provider or supplier. In addition to these
changes, for consistency we have made a number of technical and
formatting changes.
The MSP provisions in section 1862(b) of the Act establish that
Medicare has a direct right of recovery against a primary payer.
Currently under Sec. 405.926(k), determinations under these provisions
that Medicare has a recovery against a particular primary payer, are
not initial determinations for purposes of part 405 subpart I.
Consequently, although the primary payer may dispute the recovery claim
where Medicare pursues recovery against the applicable plan, it has no
formal appeal rights. We propose to revise Sec. 405.926(k) by creating
an exception to the broad rule in Sec. 405.926(k) to reflect the
proposed addition of Sec. 405.924(b)(15). The proposed revision would
provide an exception to Sec. 405.926(k) where there is an initial
determination under Sec. 405.924(b)(15) (where Medicare is pursuing
recovery directly from an applicable plan). We also propose to add a
new Sec. 405.926(a)(3) to clarify that Medicare's determination
regarding
[[Page 78805]]
who/what entity it will pursue with respect to an MSP recovery claim is
not an initial determination for purposes of part 405 subpart I.
Because Medicare has the right to recover conditional payments from the
beneficiary, the primary payer, or any other entity that has the
proceeds from payment by the primary plan, Medicare's decision
regarding who/what entity it is pursuing recovery from is not subject
to appeal. We also propose to add the word ``facilitates'' to the
existing ``sponsors or contributes to'' language in Sec. 405.926(k) in
recognition of our longstanding position that the concept of employer
sponsorship or contribution has always included facilitation efforts.
Finally for consistency, we are proposing several technical changes.
We propose to add a new Sec. 405.947, Notice to the beneficiary of
an applicable plan's request for a redetermination, to add language
satisfying the requirement at section 1862(b)(2)(B)(viii) of the Act
that the beneficiary receive notice of the applicable plan's intent to
appeal where Medicare is pursuing recovery directly from the applicable
plan. As the beneficiary would not be a party to the appeal at the
redetermination level or subsequent levels of appeal, we believe that a
single notice at the redetermination level satisfies the intent of this
provision. We also propose that the required notice be issued by the
contractor adjudicating the redetermination request in order to ensure
clarity and consistency in the wording of the notice.
III. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995.
IV. Response to Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
V. Regulatory Impact Statement
We have examined the impact of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(February 2, 2011), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
section 202 of the Unfunded Mandates Reform Act of 1995 (March 22,
1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August 4,
1999) and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). A
regulatory impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year).
We have determined that the effect of this proposed rule on the economy
and the Medicare program is not economically significant. The proposed
rule would provide a formal administrative appeal process for MSP
recovery claims where the applicable plan is the identified debtor, as
opposed to the current process which requires a CMS contractor to
consider any defense submitted by an applicable plan but does not
provide formal administrative appeal rights.
The RFA requires agencies to analyze options for regulatory relief
of small entities. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and small governmental
jurisdictions. Most hospitals and most other providers and suppliers
are small entities, either by nonprofit status or by having revenues of
less than $7.0 million to $35.5 million in any 1 year. Individuals and
States are not included in the definition of a small entity. We have
determined and we certify that this proposed rule would not have a
significant economic impact on a substantial number of small entities
because there is and will be no change in the administration of the MSP
provisions. The proposed changes would simply expand or formalize
existing rights with respect to MSP recovery claims pursued directly
from an applicable plan. Therefore, we are not preparing an analysis
for the RFA.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis (RIA) if a rule may have a significant
impact on the operations of a substantial number of small rural
hospitals. This analysis must conform to the provisions of section 603
for proposed rules of the RFA. For purposes of section 1102(b) of the
Act, we define a small rural hospital as a hospital that is located
outside of a Metropolitan Statistical Area for Medicare payment
regulations and has fewer than 100 beds. We have determined that this
proposed rule would not have a significant effect on the operations of
a substantial number of small rural hospitals because it would simply
expand and/or formalize existing rights with respect to MSP recovery
claims pursued directly from an applicable plan. Therefore, we are not
preparing an analysis for section 1102(b) of the Act.
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2013, that
threshold is approximately $141 million. This proposed rule has no
consequential effect on State, local, or tribal governments or on the
private sector because it would simply expand and/or formalize existing
rights with respect to MSP recovery claims pursued directly from an
applicable plan.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on State
and local governments, preempts State law, or otherwise has Federalism
implications. Since this regulation does not impose any costs on State
or local governments, the requirements of Executive Order 13132 are not
applicable.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects in 42 CFR Part 405
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medical devices, Medicare, Reporting and
recordkeeping requirements, Rural areas, X-rays.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services proposes to amend 42 CFR Part 405 as set forth
below:
PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
0
1. The authority citation for part 405 reads as follows:
Authority: Secs. 205(a), 1102, 1861, 1862(a), 1869, 1871, 1874,
1881, 1886(k) of the Social Security Act (42 U.S.C. 405(a),
[[Page 78806]]
1302, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr and
1395ww(k)), and sec. 353 of the Public Health Service Act (42 U.S.C.
263a)
0
2. Amend Sec. 405.900 by revising paragraph (a) to read as follows:
Sec. 405.900 Basis and scope.
(a) Statutory basis. This subpart is based on the following
provisions of the Act:
(1) Section 1869(a) through (e) and (g) of the Act.
(2) Section 1862(b)(2)(B)(viii) of the Act.
* * * * *
0
3. Amend Sec. 405.902 by adding the definition ``Applicable plan'' in
alphabetical order to read as follows:
Sec. 405.902 Definitions.
* * * * *
Applicable plan means liability insurance (including self-
insurance), no-fault insurance, or a workers' compensation law or plan.
* * * * *
0
4. Amend Sec. 405.906 as follows:
0
A. Revising the section heading.
0
B. Adding new paragraph (a)(4).
0
C. Amending paragraph (c) by adding a sentence at the end of the
paragraph.
The additions and revision read as follows:
Sec. 405.906 Parties to the initial determinations, redeterminations,
reconsiderations, hearings, and reviews.
(a) * * *
(4) An applicable plan for an initial determination under Sec.
405.924(b)(15) where Medicare is pursuing recovery directly from the
applicable plan. The applicable plan is the sole party to an initial
determination under Sec. 405.924(b)(15) (that is, where Medicare is
pursuing recovery directly from the applicable plan).
* * * * *
(c) * * *. This paragraph (c) does not apply to an initial
determination with respect to an applicable plan under Sec.
405.924(b)(15).
0
4. Amend Sec. 405.910 as follows:
0
A. Adding paragraph (e)(4).
0
B. Revising paragraph (i)(4).
The addition and revision read as follows:
Sec. 405.910 Appointed representatives.
* * * * *
(e) * * *
(4) For an initial determination of a Medicare Secondary Payer
recovery claim, an appointment signed by an applicable plan which has
party status in accordance with Sec. 405.906(a)(1)(iv) is valid from
the date that appointment is signed for the duration of any subsequent
appeal, unless the appointment is specifically revoked.
* * * * *
(i) * * *
(4) For initial determinations and appeals involving Medicare
Secondary Payer recovery claims where the beneficiary is a party, the
adjudicator sends notices and requests to both the beneficiary and the
beneficiary's representative, if the beneficiary has a representative.
* * * * *
0
5. Amend Sec. 405.921 as follows:
0
A. In paragraph (a)(1), removing ``;'' and adding in its place ``.''
0
B. In paragraph (a)(2) introductory text, removing the phrase ``must
contain--'' and adding in its place the phrase ``must contain all of
the following:''
0
C. In paragraphs (a)(2)(i) and (a)(2)(ii), removing ``;'' and adding in
its place ``.''
0
D. In paragraph (a)(2)(iii), removing ``; and'' and adding in its place
``.''
0
E. Redesignating the second and third sentences of paragraph (b)(1) as
paragraph (b)(1)(i) and (ii), respectively.
0
F. In paragraph (b)(2) introductory text, removing the phrase ``must
contain:'' and adding in its place the phrase ``must contain all of the
following:''
0
G. In paragraphs (b)(2)(i) through (b)(2)(iv), removing ``;'' and add
in its place ``.''
0
H. In paragraph (b)(2)(v), removing ``; and'' and add in its place
``.''
0
I. Adding paragraph (c) to read as follows:
Sec. 405.921 Notice of initial determination.
* * * * *
(c) Notice of initial determination sent to an applicable plan--(1)
Content of the notice. The notice of initial determination under Sec.
405.924(b)(15) must contain all of the following:
(i) The reasons for the determination.
(ii) The procedures for obtaining additional information concerning
the contractor's determination, such as a specific provision of the
policy, manual, law or regulation used in making the determination.
(iii) Information on the right to a redetermination if the
liability insurance (including self-insurance), no-fault insurance, or
workers' compensation law or plan is dissatisfied with the outcome of
the initial determination and instructions on how to request a
redetermination.
(iv) Any other requirements specified by CMS.
(2) [Reserved]
0
6. Amend Sec. 405.924 as follows:
0
A. In paragraph (b) introductory text, removing the phrase ``with
respect to:'' and add in its place the phrase ``with respect to any of
the following:''
0
B. In paragraph (b)(1) through (b)(11) removing ``;'' and adding in its
place ``.''
0
D. In paragraph (b)(12) introductory text, removing the ``:'' and
adding in its place ``--''.
0
C. Adding paragraph (b)(15).
The addition reads as follows:
Sec. 405.924 Actions that are initial determinations.
* * * * *
(b) * * *
(15) Under the Medicare Secondary Payer provisions of section
1862(b) of the Act that Medicare has a recovery claim if Medicare is
pursuing recovery directly from an applicable plan. That is, there is
an initial determination with respect to the amount and existence of
the recovery claim.
* * * * *
0
7. Amend Sec. 405.926 as follows:
0
A. In the introductory text, removing the phrase ``not limited to -''
and adding in its place the phrase ``not limited to the following:''
0
B. In the introductory text of paragraph (a), removing the phrase ``for
example -'' and adding in its place the phrase ``for example one of the
following:''
0
C. In paragraphs (a)(1) and (a)(2), removing ``;'' and adding in its
place ``.''
0
D. Adding paragraph (a)(3).
0
E. In paragraphs (b) through (j), removing ``;'' and adding in its
place ``.''
0
F. Revising paragraph (k).
0
G. In paragraphs (l) through (q), removing ``;'' and adding in its
place ``.''
0
H. In paragraph (r), removing ``; and'' and adding in its place ``.''
The addition and revision read as follows:
Sec. 405.926 Actions that are not initial determinations.
* * * * *
(a) * * *
(3) Determination under the Medicare Secondary Payer provisions of
section 1862(b) of the Act of the debtor for a particular recovery
claim.
* * * * *
(k) Except as specified in Sec. 405.924(b)(15), determinations
under the Medicare Secondary Payer provisions of section 1862(b) of the
Act that Medicare has a recovery against an entity that was or is
required or responsible (directly, as an insurer or self-insurer; as a
third party administrator; as an employer that sponsors, contributes to
or facilitates a group health plan or a large group health plan; or
otherwise) to make payment for services or items that were
[[Page 78807]]
already reimbursed by the Medicare program.
* * * * *
0
8. Add a new Sec. 405.947 to subpart I to read as follows:
Sec. 405.947 Notice to the beneficiary of applicable plan's request
for a redetermination.
(a) The contractor adjudicating the redetermination request must
send notice of the applicable plan's appeal to the beneficiary.
(b) Issuance and content of the notice must comply with CMS
instructions.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: August 29, 2013.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
Approved: November 12, 2013.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.
[FR Doc. 2013-30661 Filed 12-26-13; 8:45 am]
BILLING CODE 4120-01-P