Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 ("MMSEA") added new mandatory reporting requirements for group health plans. The purpose of the Section 111 reporting requirements is to enable the Centers for Medicare & Medicaid ("CMS") to determine primary versus secondary payer responsibility
Under the MMSEA, Plan Administrators and Third Party Administrators (for self-insured group health plans) and insurers (for fully-insured group health plans) are considered "responsible reporting entities" or RREs. Effective January 1, 2009, RREs are required to collect and report certain participant data on a quarterly basis to CMS. RREs are required to register with the CMS Coordination of Benefits Contractor (CBOC) and reports are due to CMS based on assigned file submission timeframes listed on the RRE's profile report received from CBOC. The first quarter due dates are as early as January 1-7 for some RREs and as late as March 22-28 for other RREs.
On March 4, 2009, CMS updated its MMSEA Section 111 MSP Mandatory Reporting Group Health Plan User Guide ("GHP User Guide") which reiterated that CMS considers Health Reimbursement Arrangements ("HRAs") group health plans subject to the reporting requirements under the MMSEA. However, CMS delayed the reporting requirement for HRAs until the fourth quarter of 2010 (October - December 2010 depending on assigned file submission times). The GHP User Guide also provides that behavioral/mental healthcare services when offered as stand-alone products and coverage under TRICARE or a Medicare Advantage plan is not subject to reporting. CMS also refined the definition of Active Covered Individuals in its updated GHP User Guide.
Active Covered Individuals
Group health plans must provide information to CMS for all individuals meeting the definition of an "Active Covered Individual." Active Covered Individuals are:
- Effective January 1, 2009 - December 31, 2010, all individuals covered in a group health plan age 55 through age 64 who have coverage based on their own or a family member's current employment status;
- Effective January 1, 2011 and subsequent, all individuals covered in a group health plan age 45 through age 64 who have coverage based on their own or a family member's current employment status;
- All individuals covered in a group health plan age 65 and older who have coverage based upon their own or a family member's current employment status;
- All individuals covered in a group health plan who have been receiving kidney dialysis or who have received a kidney transplant, regardless of their own or a family member's current employment status;
- All individuals covered in a group health plan who are under age 55 (age 45 effective January 1, 2011), are known to be entitled to Medicare, and have coverage in the plan based on their own or a family member's current employment status.
Continuation coverage through the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA") is generally not considered group health plan coverage for purposes of the MMSEA. Thus, individuals receiving COBRA continuation coverage are not considered an Active Covered Individual and should not be reported to CMS. However, there is one exception, if an individual is covered under COBRA continuation coverage and is receiving dialysis or has had a kidney transplant, then that individual is considered an Active Covered Individual for reporting purposes.
If an employer has less than 20 full and/or part-time employees, and the employer is not part of a multi-employer/multiple employer group health plan, then the covered individuals under that plan do not have to be reported under the MMSEA unless a covered individual is receiving dialysis or has had a kidney transplant.
Collection and Reporting of SSNs and HICNs
In addition to other participant data, RREs must collect and report either the Medicare Health Insurance Claim Number ("HICN") or Social Security Number ("SSN") of Active Covered Individuals including spouses and dependents who are subscribers on or after January 1, 2009. For spouses and family members whose initial dates of coverage were prior to January 1, 2009, a reporting extension until first quarter of 2011 is permitted to allow group health plans the time to obtain the SSN or HICN of spouses and family members. The extension does not apply to reporting subscriber information of the employee. An RRE must submit a Medicare Health Insurance Claim Number ("HICN") when reporting on individuals under the age of 45.
Enforcement and Penalties
RREs that fail to comply with the reporting requirements of Section 111 of the MMSEA are subject to a civil monetary penalty of $1,000 for each day of noncompliance for each individual for which information should have been submitted and was not.
RREs should review the updated GHP User Guide which includes examples of Active Covered Individuals. RREs should be gathering SSNs and HICNs for Active Covered Individuals who participate in HRAs to meet the Fourth Quarter 2010 reporting extension. CMS is expected to provide further guidance for reporting HRA coverage. Finally, RREs should be gathering SSN and HICN information for spouses and family members that were enrolled in coverage prior to January 1, 2009 to meet the First Quarter 2011 reporting extension for this group of individuals.
Link to CMS GHP User Guide
CMS' Group Health Plan User Guide may be obtained on the CMS website here.