GHP Responsible Reporting Entities (RRE)

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).

CMS is locked into the GHP reporting requirements of 1395y(7)(A)  "...an entity serving as an insurer or third party administrator..."  Although CMS has not issued any written guidance, CMS has made it clear during subsequent teleconferences that the Insurer, not the TPA, is responsible for reporting, but may use a TPA as a vehicle for reporting -- editor

NGHP Responsible Reporting Entities (RREs)

42 U.S.C. 1395y(b)(8) defines a responsible reporting entity (RRE) to be an applicable plan:


“APPLICABLE PLAN- In this paragraph, the term `applicable plan' (e.g., trust --ed) means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan, or arrangement:

  • Liability insurance (including self-insurance).
  • No fault insurance.
  • Workers' compensation laws or plans.

Liability and No-Fault Insurer

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.

Employer -- Self-Insured Liability

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.

The fiduciary of Single Employer Welfare Arrangements and  Multi-Employer Welfare Arrangments (e.g., captives) are responsible for reporting.  For example, a Captive Insurer may report for all of their participating employers and may use an TPA or Agent as their vehicle for reporting.

Workers' Compensation

The Federal agency, the State agency, or self-insured employer or the employer’s insurer.  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).

Although not specifically called out like the self-insured liability insurers, self-insured Workers' Compensation plans may report in the same fashion as self-insured liability plans (see above). -- editor

Agents

For purposes of the reporting requirements at 42 U.S.C. 1395y(b)(7), agents may submit reports on behalf of :

  • Insurers for GHP, No-Fault or Liability Insurance
  • Self-insured entities for liability
  • Workers compensation laws or plans
  • TPAs for GHPs
  • Employers with self-insured or self-adminstered GHP 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.

Disclaimer -- Piatt Consutling and our staff cannot render legal, accounting or medical service.  We can only try to provide accurate and authoritative information in regard to the subject matter covered.  If legal advice or other expert assistance is required, the services of a competent professional in that area should be sought.