Referral to the Regional Office

40 - Referral to the Regional Office (Rev. 11755, Issued:12-21-22, Effective: 01-23-23, Implementation: 01-23-23) The term Medicare beneficiary identifier (MBI) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the MBI during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. Since the CMS is responsible for enforcement of the age anti-discrimination provisions for coverage under group health plans, all complaints received that may reflect such discrimination by GHPs must be treated as possible violations of the Medicare law. This includes complaints that a GHP is "taking into account" that an individual is entitled to Medicare benefits and complaints that a GHP is not providing equal benefits under the same conditions for older and younger workers and spouses. A/B MACs and DME MACs must refer any cases to the RO where a GHP or LGHP is a nonconforming plan. Cases are referred as a result of the GHP or LGHP refuses to make payment as the primary payer or performing the following actions: • Offers secondary coverage for individuals for whom Medicare is secondary; or • Refuses to reimburse Medicare for any primary benefits paid to, or on behalf of, a Medicare beneficiary. In all potential discrimination cases, the contractor obtains documentation of the alleged discrimination, such as: • A notice from the GHP and/or a copy of the plan policy; • A written description of the alleged discriminatory action(s) by the GHP from the party or parties involved; • The name and address of the individual's employer; • The individual's name and Medicare beneficiary identifier; • The name and address of the GHP or LGHP; • The individual's group health plan identification number; and • A full explanation of the reasons for the referral. All available information concerning the matter must be sent to the RO, along with an analysis of the facts. If the RO believes that the GHP may have committed a discriminatory act, the case is referred to the Central Office (CO) for facts, for consideration of whether the plan is a nonconforming group health plan, (i.e. a group health plan which at any time during a calendar year does not comply with the anti-discrimination provisions of the Act). The RO considers possible legal action to collect double damages from the nonconforming LGHP/GHP. The CO also refers nonconforming group health plans to the Internal Revenue Service for imposition of an excise tax penalty to assure compliance with the anti- discrimination provisions of the law. If the GHP, LGHP, or employer has agreed to discontinue offering secondary coverage to Medicare individuals for whom it is primary payer or has agreed to reimburse Medicare the amount of incorrect Medicare primary benefits that should have been paid by the plan, the CO includes this information in its referral. Once the CO refers a nonconforming LGHP/GHP to the IRS, it does not withdraw the referral solely because the plan has discontinued offering improper secondary coverage or has reimbursed Medicare the amount of incorrect primary benefits Medicare paid.