Medicare Advantage Plans: PAID ACT – Year One

Medicare written on Chalkboard in white chalk with a red stethoscope resting on top of the chalkboard on the right side

by P. Czuprynski

Carriers and self-insureds, or their vendors, have the ability to ask Medicare if a particular claimant is enrolled in Medicare benefits through either an electronic data request or directly via a centralized portal. The Provide Accurate Information Directly (PAID) Act, requires Medicare to provide additional Medicare Advantage Plan (Part C) and prescription plan (Part D) information associated with these requests. This additional information has been available since December 11, 2021 and uses updated HEW Software.

As of August 2022, there are almost 65 million Medicare beneficiaries, and about 30 million of them have Part C and other benefits. Medicare statistics demonstrate that Part C and D enrollment is increasing every year, which means the chances a workers’ compensation or liability claimant having Part C and Part D benefits is also increasing every year.

Because of these circumstances, and the additional information provided by Medicare, it has become paramount for carriers and self-insureds to update their protocols and workflows associated with Medicare enrollment investigation, conditional payment processes, and Section 111 reporting. Failure to do so may lead organizations to experience unintended risk, exposure, and in some circumstances litigation, many years after a settlement associated with a workers’ compensation or liability claim.

Further, annual or special enrollment periods could result in many Medicare plans being affected by a claim.

Therefore, a carrier/self-insured should consider having mechanisms or partnerships in place where a Part C or Part D plan is contacted depending on certain claim circumstances.  For example:

    • a workers’ compensation claim is accepted
    • a claimant has been on two different Part C plans since the date of incident

In this circumstance, the carrier/self-insured should consider contacting the plans to determine if they will be seeking reimbursement for treatment associated with the accepted conditions. This process should also be considered if there is an anticipated settlement(s) involving a Part C or Part D beneficiary.

IMPAXX has partnered with carriers/self-insureds, and their third-party administrators, to automate this process and confirm that Part C and Part D plans are notified of potential reimbursement opportunities. With the information available through the query process and PAID Act, we can track potential plans for reimbursement and allow carriers/self-insureds to effectively resolve matters involving Part C or D plans. To learn more, please contact our settlement consultant team at [email protected].