Attachment A_2013vj508

Attachment A – Definitions and Reporting Responsibilities
SUPPORTING DOCUMENT FOR PRA PACKAGE FOR MEDICARE
SECONDARY PAYER REPORTING RESPONSIBILITIES FOR
SECTION 111 OF THE MEDICARE, MEDICAID, AND SCHIP EXTENSION
ACT OF 2007

DEFINITIONS AND REPORTING RESPONSIBILITIES

GROUP HEALTH PLAN (GHP) ARRANGEMENTS (42 U.S.C. 1395y(b)(7)) -INSURER
For purposes of the reporting requirements at 42 U.S.C.1395y(b)(7), an insurer is an
entity that, in return for the receipt of a premium, assumes the obligation to pay claims
described in the insurance contract and assumes the financial risk associated with such
payments. In instances where an insurer does not process GHP claims but has a third
party administrator (TPA) that does, the TPA has the responsibility for the reporting
requirements at 42 U.S.C. 1395y(b)(7).
THIRD PARTY ADMINISTRATOR (TPA)
For purposes of the reporting requirements at 42 U.S.C.1395y(b)(7), a TPA is an entity
that pays and/or adjudicates claims and may perform other administrative services on
behalf of GHPs (as defined at 42 U.S.C. 1395y(b)(1)(A)(v)), the plan sponsor(s) or the
plan insurer. A TPA may perform these services for, amongst other entities, self-insured
employers, unions, associations, and insurers/underwriters of such GHPs. If a GHP is
self-funded and self-administered for certain purposes but also has a TPA as defined in
this paragraph, the TPA has the responsibility for the reporting requirements at 42 U.S.C.
1395y(b)(7).
USE OF AGENTS FOR PURPOSES OF THE REPORTING REQUIREMENTS
AT 42 U.S.C. 1395y(b)(7):
For purposes of the reporting requirements at 42 U.S.C. 1395y(b)(7), agents may submit
reports on behalf of :
•
•
•

Insurers for GHPs
TPAs for GHPs
Employers with self-insured and self-administered GHPs

Accountability for submitting the reports in the manner and form stipulated by the
Secretary and the accuracy of the submitted information continues to rest with each of the
above-named entities.
The CMS will provide information on the format and method of identifying agents for
reporting purposes.
LIABILITY INSURANCE (INCLUDING SELF-INSURANCE), NO-FAULT
INSURANCE, AND WORKERS’ COMPENSATION (42 U.S.C. 1395y(b)(8) -INSURER
For purposes of the reporting requirements for 42 U.S.C. 1395y(b)(8), a liability insurer
(except for self-insurance) or a no-fault insurer is an entity that, in return for the receipt
of a premium, assumes the obligation to pay claims described in the insurance contract
and assumes the financial risk associated with such payments. The insurer may or may
not assume responsibility for claims processing; however, the insurer has the
responsibility for the reporting requirements at 42 U.S.C. 1395y(b)(8) regardless of
whether it uses another entity for claim processing.
CLAIMANT:
For purposes of the reporting requirements at 42 U.S.C. 1395y(b)(8), “claimant”
includes: 1) an individual filing a claim directly against the applicable plan, 2) an
individual filing a claim against an individual or entity insured or covered by the
applicable plan, or 3) an individual whose illness, injury, incident, or accident is/was at
issue in “1)” or “2)”.
APPLICABLE PLAN:
For purposes of the reporting requirements at 42 U.S.C. 1395y(b)(8), the “applicable
plan” as defined in subsection (8)((F) has the responsibility for the reporting requirements
at 42 U.S.C. 1395y(b)(8). For workers’ compensation information this would be the
Federal agency, the State agency, or self-insured employer or the employer’s insurer.
NO-FAULT INSURANCE:
Trade associations for liability insurance, no-fault insurance and workers’ compensation
have indicated that the industry’s definition of no-fault insurance is narrower than CMS’
definition. For purposes of the reporting requirements at 42 U.S.C. 1395y(b)(8), the
definition of no-fault insurance found at 42 C.F.R. 411.50 is controlling.
LIABILITY SELF-INSURANCE:
42 U.S.C. 1395y(b)(2)(A) provides that an entity that engages in a business, trade or
profession shall be deemed to have a self-insured plan if it carries its own risk (whether
by a failure to obtain insurance, or otherwise) in whole or in part. Self-insurance or
deemed self-insurance can be demonstrated by a settlement, judgment, award, or other
payment to satisfy an alleged claim (including any deductible or co-pay on a liability
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insurance, no-fault insurance, or workers’ compensation law or plan) for a business, trade
or profession. See also 42 C.F.R. 411.50.
Special Considerations where liability self-insurance which is a deductible or copayment for liability insurance, no-fault insurance, or workers’ compensation is
paid to the insurer or workers’ compensation entity for distribution (rather than
directly to the claimant): As indicated in the definition of “liability self-insurance,”
such deductibles and co-payments constitute liability self-insurance, and require reporting
by the self-insured entities. However, in order to avoid two entities reporting where the
deductibles and/or co-payments are physically being paid by the insurance company or
workers’ compensation rather than the self-insured entity, CMS has determined that the
liability insurance company, no-fault insurance company, or workers’ compensation, as
appropriate, must include the self-insurance deductible or co-pay in the amount it reports.
Note that this rule only applies where the self-insurance deductible or co-pay is paid to
the insurer for distribution rather than directly to the claimant

WORKERS’ COMPENSATION LAW OR PLAN
For purposes of the reporting requirements at 42 U.S.C. 1395y(b)(8), a workers’
compensation law or plan means a law or program administered by a State (defined to
include commonwealths, territories and possessions of the United States) or the United
States to provide compensation to workers for work-related injuries and/or illnesses. The
term includes a similar compensation plan established by an employer that is funded by
such employer directly or indirectly through an insurer to provide compensation to a
worker of such employer for a work-related injury or illness. Where such a plan is
directly funded by the employer, the employer has the responsibility for the reporting
requirements at 42 U.S.C. 1395y(b)(8). Where such a plan is indirectly funded by the
employer, the insurer has the responsibility for the reporting requirements at 42 U.S.C.
1395y(b)(8).
USE OF AGENTS FOR PURPOSES OF THE REPORTING REQUIREMENTS
AT 42 U.S.C. 1395y(b)(8):
Agents may submit reports on behalf of:
•
•
•

Insurers for no-fault or liability insurance
Self-insured entities for liability insurance
Workers’ compensation laws or plans

Accountability for submitting the reports in the manner and form stipulated by the
Secretary and the accuracy of the submitted information continues to rest with each of the
above-named entities.
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TPAs of any type (including TPAs as defined for purposes of the reporting requirements
at 42 U.S.C. 1395y(b)(7) for GHP arrangements) have no reporting responsibilities for
purposes of the reporting requirements at 42 U.S.C. 1395y(b)(8) for liability insurance
(including self-insurance), no-fault insurance, or workers’ compensation. Where an entity
reports on behalf of another entity required to report under 42 U.S.C. 1395y(b)(8), it is
doing so as an agent of the second entity.
CMS will provide information on the format and method of identifying agents for
reporting purposes.

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