Federally Mandated Reporting/Disclosure Form

Program Title and Description:

Centers for Medicare and Medicaid Services (CMS) Medicare Data Match

Periodically, CMS sends the University a packet of information requesting that Missouri State verify the health insurance coverage for both current and former employees in order to determine whether Medicare insurance should be the primary or secondary payor. The packet contains a number of individual questionnaires (usually between 50-80) on specific people and requests that Missouri State indicate whether the people are still full-time employees or if they are retired, when they retired and when their university-provided health insurance terminated.

Who is Responsible for Reporting?

Primary Contact
Howard Berriman, Carrington Hall Room 118, (417) 836-6616, HowardBerriman@MissouriState.edu

Secondary Contact(s)

Where is Report Physically Located?

Copies of the completed questionnaires are kept in the Office of Human Resources, Carrington Hall - room 118.

What Should be Reported?

The University must report the periods during which specific current and former employees were (or still are) covered under the university-sponsored health insurance.

When Should it be Reported?

The reporting period is not a constant date.  The report is required to be completed within 30 days of receipt from CMS or an extension can be requested from CMS.

Where is it to be Reported?

The Data Match Questionnaires are mailed to a Medicare office in New York, NY.

Why Should it be Reported?

The University benefits by completing the data match questionnaires since confirming that a former employee should be covered by Medicare first, reduces the University’s financial liability for medical expenses that the person could incur. 

How is it Reported?

The individual questionnaires are completed by hand and mailed.

If notification is required, how is it reported?

N/A