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Mandatory Insurer Reporting for Group Health Plans (GHP)

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. 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 GHP arrangements found at 42 U.S.C. 1395y(b)(7):

  • Added reporting rules, but did not eliminate any previously existing Medicare Secondary Payer (MSP) statutory provisions or regulations.
    Include penalties for noncompliance.
  • Allow CMS to share information on Medicare Part A entitlement and enrollment under Medicare Part B.
  • Include who must report, referred to as a responsible reporting entity (RRE): “an entity serving as an insurer or third party administrator for a group health plan…and, in the case of a group health plan that is self-insured and self-administered, a plan administrator or fiduciary”.
  • Include what must be reported.
  • Specify the form and manner of reporting. GHP reporting is done on a quarterly basis in an electronic format.

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

A GHP organization that must report under Section 111 is an entity serving as an insurer or third party administrator (TPA) for a group health plan. In the case of a group health plan that is self-insured and self-administered, this would be the plan administrator or fiduciary. These organizations are referred to as Section 111 GHP responsible reporting entities, or RREs. GHP RREs may use agents to submit data on their behalf but the RRE remains solely responsible and accountable for adhering to the Section 111 reporting requirements and accuracy of the data submitted.

Reporting

The purpose of Section 111 reporting is to enable Medicare to correctly pay for the health insurance benefits of Medicare beneficiaries by determining primary versus secondary payer responsibility. Section 111 authorizes CMS and GHP RREs to electronically exchange health insurance benefit entitlement information. On a quarterly basis, an RRE must submit a file of information about employees and dependents who are Medicare beneficiaries with employer GHP coverage that may be primary to Medicare. In exchange, CMS provides the RRE with Medicare entitlement and enrollment information for those individuals in the GHP that can be identified as Medicare beneficiaries. This mutual data exchange helps to ensure that claims will be paid by the appropriate organization at first billing. The Section 111 GHP reporting process also includes an option to exchange prescription drug coverage information to coordinate benefits related to Medicare Part D.

Reporting Requirements - GHP User Guide and Alerts

Reporting requirements are documented in the MMSEA Section 111 Medicare Secondary Payer (MSP) Mandatory Reporting GHP User Guide which is available for download on the GHP User Guide page. The GHP User Guide is the primary source for Section 111 reporting requirements. RREs must also be sure to refer to important information published on the GHP Alerts page. To obtain the most up to date information and requirements, refer to the GHP 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 GHP Training Materials page.

Registration and the Section 111 Coordination of Benefits Secure Website (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.

GHP 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 and submit online queries of Medicare entitlement. Refer to the GHP 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 GHP Town Hall Teleconferences to provide updated policy and technical information related to Section 111 reporting. Announcements for upcoming GHP Town Hall events are posted to the GHP What’s New page. Transcripts from the current year can be found on the GHP Transcripts page while prior year transcripts can be found on the Archive page.

Comments and inquiries regarding Section 111 GHP Mandatory Reporting may be directed via e-mail to CMS at PL110-173SEC111-comments@cms.hhs.gov.

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

Unsolicited Response File

Section 111 GHP RREs can elect to receive the GHP Unsolicited MSP Response File. Through this process, a monthly file will be sent to the participating RRE to notify them whenever another entity changes or deletes MSP information previously submitted by them. The file will contain information about the RRE’s prior submission and information regarding the data modifications that were applied, the reason for the change, and the source of the new information. While receipt of this file is optional, GHP RREs are encouraged to consider participation since it improves the overall accuracy of MSP information used and stored by Medicare, RREs, and employer GHP sponsors. More information on the benefits of the Unsolicited Response File and how to enroll in this process can be found in the GHP User Guide.

Compliance

In addition to the provisions for GHP arrangements found at 42 U.S.C. 1395y(b)(7), please refer to the GHP User Guide and CMS Guidance published in the Downloads section below.

How to sign-up for Mandatory Insurer Reporting (GHP) Web page updates

CMS provides the ability for you to be automatically notified when changes are made to the Mandatory Insurer Reporting (GHP) Web pages. If you have not already signed up for these notifications, please click the Sign-up Mandatory Insurer Reporting (GHP) Web Page Update Notification link found in the Related Links section below to subscribe. When notifications and new information are available, you will be notified via e-mail. Announcements regarding updates will also be posted to the Mandatory Insurer Reporting (GHP) What’s New page.