What Insurers Need to Know About Mandatory Reporting

Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) added new mandatory reporting requirements for group health plans (GHP) and non-group health plans (NGHP), such as liability insurance (including self-insurance), no-fault insurance, and workers’ compensation.

The implementation dates for most casualty insurers have come and gone, but there’s still time for compliance.


The Medicare Secondary Payer (MSP) provisions in Section 111 require certain entities to report specified information regarding GHP and NGHP insurance coverage sponsored by employers.

Reporting requirements apply when an insured claimant is a Medicare beneficiary. All applicable claims involving a Medicare beneficiary when there is a settlement, judgment, award or other payment, must be reported to the Centers for Medicare & Medicaid Services (CMS).

The purpose of the reporting requirements is to enable CMS to determine whether it is a primary or secondary payer for a claim.

Medicare as the Secondary Payer

In general, Medicare is a secondary payer to GHPs for Medicare beneficiaries who:

  • Are age 65 and older and who have GHP coverage on the basis of their own or their spouse’s current employment with an employer that has at least 20 employees;
  • Are younger than 65 and disabled and who have GHP coverage on the basis of their own or a family member’s current employment with an employer having at least 100 employees; or
  • Have End Stage Renal Disease (ESRD) and who have GHP coverage on any basis. (In this case, Medicare is secondary for a 30 month “coordination” period.)

As noted above, Medicare is also a secondary payer to certain types of NGHP insurance coverage – liability insurance (including self-insurance), no-fault insurance and workers’ compensation.

Implementation Dates

The 2007 amendments to the MSP provisions required RREs to report specified information regarding GHPs and NGHPs to CMS beginning this year.

GHPs had until Jan. 1, 2009 to implement a system of reporting. NGHPs had until July 1, 2009 to do so. All GHP responsible reporting entities (RREs) (except HRA RREs) had until Oct. 1 to submit their first Section 111 production files.

HRA-only GHP RREs, however, have until June 30, 2010 to complete registration and Sept. 30, 2010 to complete testing. HRA-only GHP RREs must submit their first Section 111 production files between Oct. 1, 2010 and Dec. 31, 2010, based upon a predetermined schedule with the Coordination of Benefits Contractor (COBC).

Technical Support

CMS is offering MMSEA Section 111 computer-based training (CBT) for individuals and entities that are RREs. The CBT is designed to help RREs with the actual reporting process. If you are an RRE (or have contracted with an RRE to act as its agent for purposes of the mandatory reporting), this training is for you.

CMS is also holding several teleconferences. All town hall teleconferences are held from 1 pm to 3 pm EST, unless otherwise noted.

 Future Town Hall teleconference dates for GHPs:

  • November 16, 2009
  • December 10, 2009

Click here for more information.

Future Town Hall teleconference dates for NGHPs:

  • November 17, 2009
  • December 8, 2009
  • December 15, 2009 

 Click here for more information.

Earlier this year, Claims asked Kathy Donovan, senior compliance counsel for Insurance Compliance Solutions at Wolters Kluwer Financial Services, about Medicare reporting and what insurers will need to do to stay compliant. Read what she had to say.

For a complete, up-to-date overview of the MSP reporting requirements, check out the Mandatory Insurer Reporting section on CMS’ Web site.

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