CMS Pub. 100-11, ch. 14, § 20.4

As set forth in Section 1862(b)(2)(A)(ii) of the Social Security Act, Medicare payment

may not be made if payment has been made or can reasonably be expected to be made

under a workmen’s compensation law. As further specified in 42 CFR § 460.180(d) of

the PACE regulation, Medicare does not pay for services to the extent that Medicare is

not the primary payer. The PACE organization must ask questions to secure insurance

information and identify payers other than PACE and whether PACE is the primary or

secondary payer. The beneficiary must be queried about other possible coverage that may

be primary to PACE.

The Federal Black Lung Program is a form of workmen’s compensation. As such,

Medicare does not pay for services covered under the Federal Black Lung Program

because the Black Lung program pays for covered services in full. As such, the PACE

organization may seek payment from the Federal Black Lung Program on behalf of Black

Lung-eligible PACE participants. To the extent that the participant has been paid by the

Federal Black Lung Program for services furnished by the PACE organization, the PACE

organization may seek payment from the participant. Illnesses or injuries not related to

black lung would be covered by the PACE organization.

The PACE organization is required to report all Medicare Secondary Payer (MSP)

information to CMS. As outlined in the final “45-Day Notice” for 2010, released on April

6, 2009, there has been a policy change in the way plans are to report the MSP

information. The new policy is outlined in the final “45-Day Notice” for 2010, released

on April 6. (The Notice may be viewed

at: http://www.cms.hhs.gov/medicareadvtgspecratestats/ad/List.asp. This change now

supersedes the requirement for plans to submit the results of membership survey data to

CMS via the new Transaction 85 for the 2010 MSP factor. Plans should ignore the

information outlined in the April Release notification sent in January 2010, regarding the

new Transaction 85.

Since CMS has already calculated 2009 MSP plan level factors and they are in use, there

is no need to submit data on the new Transaction 85. Anything submitted will be ignored

by the system. The COB process as outlined in the “45-Day Notice” is the process that

will be used for 2010 and going forward.