June 15, 2009

CMS Again Updates Mandatory Insurer Reporting User Guide and Issues Other Guidance

In late May 2009, the Centers for Medicare & Medicaid Services (CMS) again revised its guidance on data-reporting obligations for "Responsible Reporting Entities" (RREs). Those obligations require insurers, third party administrators (TPAs) and a plan administrator or fiduciary of a self-insured/self-administered group health plan to collect certain data for certain classes of participants and beneficiaries and electronically file the information with Medicare in accordance with detailed rules established by CMS.1 This Capital Checkup summarizes key issues addressed in the updated guidance:

Background: Who Must Register and Comply?

The following "Responsible Reporting Entities" (RREs) must register with CMS and report data:

  • Health insurance companies,
  • TPAs, defined as entities that pay and/or adjudicate claims on behalf of group health plans, and
  • Plan administrators or fiduciaries of self-insured, self-administered group health plans. However, if the plan uses a TPA to pay claims, then CMS has stated that the TPA is the RRE.

RREs may use agents to submit reports on their behalf, but accountability for submitting accurate reports rests with the responsible entity, not the agent. By now, plan sponsors of self-insured/self-administered group health plans should already have registered and set up their accounts with CMS.2

Employer-sponsored plans that are fully insured do not have any reporting obligations. However, since the insurer does have a reporting obligation, many employers and multiemployer plan sponsors are receiving requests from insurers for SSNs and HICNs for plan participants, spouses and certain dependents.

Health Reimbursement Arrangements

Many benefits administrators and plan sponsors with HRAs requested that CMS exempt HRAs from the reporting requirements in the same way that health Flexible Spending Arrangements (FSAs) are currently exempt. This is because HRAs are generally not used without a companion health insurance plan that contains the actual claims information necessary to coordinate with Medicare, and HRAs do not keep records in the same manner as a claims-paying health insurer or administrator.

In March 2009, CMS gave RREs a reprieve in reporting HRA information when it decided that RREs would not have to submit quarterly reporting files on HRAs until the fourth quarter of 2010. In the updated guidance, CMS states explicitly that plans that self-administer only their HRA (and thus are RREs only with respect to HRA coverage) do not need to register with CMS at this time.3 Instead, these RREs have until May 1, 2010 to register with CMS. RREs must register by May 1 in order to leave sufficient time for testing to be completed before production files are due in the fourth quarter of 2010.

Individuals Known to be Entitled to Medicare

RREs must submit data on individuals under age 554 who are "known to be entitled to Medicare" and covered by the plan based on their own or a family member's current employment status. CMS has clarified that it expects RREs to "know" that an individual is entitled to Medicare if the plan has the person's HICN on file or the plan is paying primary or secondary to Medicare for that person. To identify these situations, CMS cautions RREs to check their enrollment files, coordination of benefits files or claims payment records. CMS further states that it does not want RREs to report on every covered individual under the age threshold if the RRE has no reason to believe they are entitled to Medicare.5

Collecting HICNs and SSNs

Recognizing that some RREs are having difficulty collecting HICNs or SSNs for some people, in late May, CMS posted new materials on its Web site to assist RREs in collecting these data elements. One document is a new form6 that can be used if an individual refuses to furnish a HICN or SSN. If the form is completed, CMS will consider an RRE compliant for purposes of its next Section 111 file submission. The RRE must:

  • Obtain a signed copy of the five-page form posted on the CMS Web site (which contains a picture of a Medicare ID card)7 from participants who have refused to furnish a HICN or SSN (or, more likely, whose family members have refused to provide such information),
  • Have the participant re-sign and date this form once every 12 months, and
  • Retain the documentation.

The form shows a picture of a Medicare ID card and asks one person (the participant) to provide information about Medicare enrollment status of the participant, his/her spouse, and his/her covered family members. It also asks for the person's HICN or SSN if the HICN is not available. The form contains one section that is to be completed if the participant refuses to provide the information. That section warns the signer that if he or she is a Medicare beneficiary, he or she may be violating his or obligations as a Medicare beneficiary to assist Medicare in coordinating benefits.

Implications for Plan Sponsors

CMS representatives have been advising HRA-only plans that have already registered to withdraw the registration and wait until next year to register. Any plan sponsor in this situation should contact the EDI representative assigned to the plan during the Section 111 registration process for advice on how to proceed.

Plan sponsors having difficulty collecting HICNs or SSNs, especially from dependents, should consider using the form CMS has devised to collect the required information about those individuals for whom data must be reported. RREs must currently submit HICNs or SSNs for participants and also for dependents whose initial date of coverage was January 1, 2009 or later. This form could be used to collect data from those individuals, as well as from individuals covered prior to January 1. (RREs have until their first reporting deadline in 2011 to submit HICNs or SSNs for spouses and other family members whose initial date of coverage was prior to January 1, 2009.)

For plans with an open enrollment process, the form could be used annually as part of that process. For plans without an annual open enrollment process that opt to follow the process set out in the alert discussed above, the RRE must arrange to have this form signed and dated once every 12 months.

Information on reporting requirements, criteria and implementation deadlines is available in The Segal Company's January 2009 Bulletins, "Medicare Mandatory Insurer Reporting for Public Sector Health Plans" or "Plan Sponsors and Medicare Mandatory Insurer Reporting" (for multiemployer plans).

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As with all issues involving the interpretation or application of laws, plan sponsors should rely on their legal counsel for authoritative advice. The Segal Company is available to assist plan sponsors in complying with these reporting requirements.

The new data-reporting requirements were enacted in Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (Public Law 110-173), and were originally effective January 1, 2009. For information about the MMSEA, see one of The Segal Company's January 2009 Bulletins, "Medicare Mandatory Insurer Reporting for Public Sector Health Plans" or "Plan Sponsors and Medicare Mandatory Insurer Reporting" (for multiemployer plans). The implementation guidance is available through the following page of the CMS Web site: http://www.cms.hhs.gov/MandatoryInsRep. This information is continually updated. Of particular significance is the MSP Mandatory Reporting GHP User Guide, which CMS has already revised numerous times since the original posting. (Click on the following text to return to the Capital Checkup.)
For information on registration and the account set-up process, see Segal's March 2009 Capital Checkup, "CMS Updates Mandatory Insurer Reporting Requirements and User Guide." (Click on the following text to return to the Capital Checkup.)
GHP User Guide Version 2.3, Section (dated May 22, 2009): http://www.cms.hhs.gov/MandatoryInsRep/02_GHP.asp (Click on the following text to return to the Capital Checkup.)
This age threshold decreases to 45 effective January 1, 2011. (Click on the following text to return to the Capital Checkup.)
This discussion is found in the section called "Additional Notes on Active Covered Individuals" in section 7.1.2 of the GHP User Guide. (Click on the following text to return to the Capital Checkup.)
The ALERT: Compliance Guidance Regarding Obtaining Individual HICNs and/or SSNs for Group Health Plan (GHP) Reporting is on the CMS Web site. (Click on the following text to return to the Capital Checkup.)
The form is on the CMS Web site. (Click on the following text to return to the Capital Checkup.)

Capital Checkup is The Segal Company's periodic electronic newsletter summarizing activity with respect to health care and related subjects. Capital Checkup is for informational purposes only. It is not intended to provide guidance on current laws or pending legislation. On all issues involving the interpretation or application of laws and regulations, plan sponsors should rely on their attorneys for legal advice.


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