Mandatory Insurer Reporting for Non-Group Health Plans (NGHP)

Mandatory Insurer Reporting for Non-Group Health Plans (NGHP)

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added mandatory reporting requirements with respect to Medicare beneficiaries who have coverage under group health plan (GHP) arrangements as well as for Medicare beneficiaries who receive settlements, judgments, awards or other payment from liability insurance (including self-insurance), no-fault insurance, or workers’ compensation, collectively referred to as Non-Group Health Plan (NGHP) or NGHP insurance. Note: Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 is sometimes referred to as “Section 111”. The term “Section 111” will be used on these pages for ease of reference.

The provisions for Liability Insurance, No-Fault Insurance, and Workers’ Compensation found at 42 U.S.C. 1395y(b)(8):

• Added reporting rules, but did not eliminate any previously existing Medicare Secondary Payer (MSP) statutory provisions or regulations
• Did not change existing processes for MSP recovery and self-reporting other insurance to CMS
• Include penalties for noncompliance
• Define who must report, a responsible reporting entity (RRE), as “an applicable plan”:  "...[T]he term 'applicable plan' means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan, or arrangement: (i) Liability insurance (including self-insurance). (ii) No fault insurance. (iii) Workers' compensation laws or plans."
• Include what must be reported
• Specify the form and manner of reporting

The Section 111 statutory language, Paperwork Reduction Act Federal Register Notice and Supporting Statement can be found in the Downloads section below.

Who Must Report

An organization that must report under Section 111 is referred to as a responsible reporting entity (RRE). In general terms, NGHP RREs include liability insurers, no-fault insurers, and workers’ compensation plans and insurers. RREs may also be organizations that are self-insured with respect to liability insurance, no-fault insurance, and workers’ compensation.

You must refer to the information provided in the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No-Fault Insurance, and Workers’ Compensation User Guide (NGHP User Guide) Chapter III: Policy Guidance found as a download on the NGHP User Guide page for a complete explanation of who must report. The Responsible Reporting Entities section of this chapter provides a detailed definition of an NGHP RRE, including scenarios related to corporate structure, bankruptcy, self-insurance pools and other insurer relationships that have a bearing on what entity must report under various circumstances.

Reporting

The purpose of Section 111 reporting is to enable CMS to pay appropriately for Medicare-covered items and services furnished to Medicare beneficiaries. Section 111 NGHP reporting of applicable liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claim information helps CMS determine when other insurance coverage is primary to Medicare, meaning that it should pay for the items and services first before Medicare considers its payment responsibilities.

Reporting is accomplished by either the submission of an electronic file of liability, no-fault, and workers’ compensation claim information, where the injured party is a Medicare beneficiary, or by entry of this claim information directly into a secure Web portal, depending on the volume of data to be submitted. Upon receipt of this information, CMS checks whether the injured party associated with the claim report is a Medicare beneficiary, and determines if the other insurance is primary to Medicare. CMS then uses this information in the Medicare claims payment process and, if Medicare paid first when it should not have, uses it to seek repayment from the other insurer or the Medicare beneficiary.

Reporting Requirements – NGHP User Guide and Alerts

Reporting requirements are documented in the NGHP User Guide which is available as a series of downloads on the NGHP User Guide page. The NGHP User Guide is made up of five chapters: Introduction and Overview, Registration Procedures, Policy Guidance, Technical Information, and Appendices. Each chapter can be referenced independently, but are designed to function together to provide complete information and instructions for NGHP reporting.

The NGHP User Guide is the primary source for Section 111 reporting requirements. RREs must also be sure to refer to important information published on the NGHP Alerts page. To obtain the most up to date information and requirements, refer to the NGHP User Guide and all pertinent alerts published subsequent to the current version of the User Guide. Comprehensive Computer-Based Training (CBT) modules covering all aspects of Section 111 reporting can be found on the NGHP Training Material page.

Please see the MMSEA Section 111 Mandatory Insurer Reporting Quick Reference Guide for Non-Group Health Plan (NGHP) Insurers download on this page for more general information.

Registration and the Section 111 COBSW

Section 111 RREs are required to register for Section 111 reporting and fully test the data exchange before submitting production files. The registration process provides notification to CMS of the RRE’s intent to report data to comply with the requirements of Section 111 of the MMSEA.

NGHP RREs must register on the Section 111 COB Secure Website (COBSW), This interactive Web portal may also be used to maintain current account information, monitor reporting file processing, query an individual’s Medicare status and, for RREs with a low volume of information to report, directly enter NGHP claim information. Refer to the NGHP User Guide and the How to Get Started download found under the How To menu option of the Section 111 COBSW for registration instructions. The link to the Section 111 COBSW can be found in the Related Links section below

Reporting Assistance

After registration, you will be assigned an Electronic Data Interchange (EDI) Representative to assist you with the reporting process and answer related technical questions.

CMS conducts NGHP Town Hall Teleconferences to provide updated policy and technical information related to Section 111 reporting. Announcements for upcoming NGHP Town Hall events are posted to the NGHP What’s New page. Transcripts from the current year can be found on the NGHP Transcripts Page while prior year transcripts can be found on the Archive page.

The Section 111 Resource Mailbox, at PL110-173SEC111-comments@cms.hhs.gov, is a vehicle that Responsible Reporting Entities (RREs) may use to send CMS policy-related questions regarding the Medicare Secondary Payer (MSP) reporting requirements included in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007.  RREs are requested to send only policy-related questions to the Section 111 Resource Mailbox.

If an RRE has a technical question, and if you are unable to contact your Electronic Data Interchange (EDI) Representative, for any reason, call the EDI Hotline at (646) 458-6740. If you have not registered to become an RRE, please directly contact the Benefits Coordination Recovery Center (BCRC) at 1-855-798-2627 (TTY/TDD: 1-855-797-2627 for the hearing and speech impaired).

Comprehensive Computer-Based Training (CBT) modules covering all reporting and registration requirements can be viewed from the NGHP Training Material page.

Compliance

In addition to the provisions found at 42 U.S.C. 1395y(b)(8), please refer to the NGHP User Guide and CMS Guidance published in the Downloads section below.