Medicare wants to know who is on your plan. Someone has to tell it.
Section 111 of the Medicare, Medicaid, and SCHIP Extension Act requires group health plans to report to CMS the people on their plans who are Medicare beneficiaries, so Medicare knows who pays first. For a fully insured employer the insurer usually does it. For a self-funded plan or an HRA, the duty lands closer to the employer.
The question is who the reporting entity is.
Section 111 puts the duty on a “responsible reporting entity,” and which party that is depends on how the plan is funded.
Fully Insured Plans
The insurance carrier is the responsible reporting entity and submits the files. The employer’s job is to give the carrier accurate eligibility data: names, dates of birth, Social Security or Medicare numbers and coverage dates.
Self-Funded Plans
The plan sponsor is the reporting entity, and may name its third-party administrator or another vendor as its agent. The sponsor remains responsible for the result, so it needs to confirm that the agent is registered and submitting.
HRAs and Similar Accounts
CMS treats health reimbursement arrangements as group health plan arrangements for reporting. An employer with an HRA, including a retiree HRA or an individual coverage HRA, has to identify who reports for it. This is often missed because the HRA sits outside the carrier relationship.
What Gets Reported
Identifying details for each person covered who is, or may be, a Medicare beneficiary, plus coverage effective and termination dates and the relationship to the policyholder. The files go to CMS on a quarterly schedule through its secure site, after registration and testing.
Why It Exists
Medicare is secondary to an employer plan in many situations, including active employees at larger employers. CMS needs the data to pay claims in the right order and recover payments made by mistake.
The Penalty Is Statutory
The law allows civil money penalties of up to $1,000 for each day of noncompliance for each individual. In practice most problems are found when claims are paid in the wrong order, so accurate data is the first protection.
Four problems that show up in audits.
No One Knows Who Reports
The carrier assumes the employer does it, the employer assumes the carrier does. For a self-funded or HRA plan, nobody does.
Bad Eligibility Data
Missing Social Security numbers, wrong dates of birth and coverage that was never terminated in the file. Retiree and COBRA populations are the worst.
The HRA Is Overlooked
An employer sets up an HRA for retirees or active employees without telling the reporting agent. The HRA is a plan, and it needs a reporting entity.
Changes Are Not Passed On
A new administrator, a new carrier or a new plan year can reset the registration. Reporting has to move with the plan.
The questions employers ask about Section 111.
Six questions that come before the CMS letter does.
Does a fully insured employer have to report?
The insurance carrier reports for a fully insured plan. The employer still has to supply accurate data and keep it current.
Who reports for a self-funded plan?
The plan sponsor is the responsible reporting entity and can appoint its administrator as agent. The sponsor stays responsible, so it should confirm the agent is reporting.
Does it apply to an HRA?
Yes. CMS treats HRAs as group health plan arrangements for reporting. Someone has to be named as the reporting entity.
Do we report only people over 65?
The entity reports anyone who is or may be a Medicare beneficiary, which includes people under 65 who are on disability. The reporting entity queries CMS to find out.
What are the penalties?
The statute allows civil money penalties of up to $1,000 per day per individual for noncompliance. Practically, most trouble comes from claims paid in the wrong order.
Who helps with this?
We work out who the reporting entity is for each plan, check that the carrier or administrator is reporting, and set it up with the partners who handle it when an HRA or self-funded plan needs it.
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General information about Medicare Secondary Payer reporting, not legal or tax advice. Plan-specific questions belong with your tax adviser or counsel, and we will bring them in.
Related guides.
Medicare Coordination Guidance
Who pays first when Medicare and an employer plan overlap.
Medicare HRA Premium Reimbursement
Reimbursing Medicare premiums for retirees.
Compliance Calendar
The dated filings and notices employers owe each year.
Where the Rules Come From.
The laws and rules named on this page link to the statute or regulation they come from. This is general information, not legal or tax advice, and rules change, so check the current text.
Medicare Secondary Payer Rules (42 U.S.C. 1395y)
Includes the Section 111 reporting requirement for group health plans, in subsection (b)(8).
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