Updated Section 111 User Guide Released
On April 24, 2023, CMS released Version 7.1 of the NGHP Section 111 User Guide to include a new Section 6.1.13 addressing subscription insurance policies. The new Section 6.1.13 provides the guidance below.
In a subscription insurance policy arrangement, two or more insurers enter into an agreement whereby the risk of the insurance policy is spread among the various insurance entities in some agreed-upon ratio. In such arrangements, a lead insurer is designated for various administrative and business purposes. While there may be many co-insurers on a subscription insurance policy, there is only one lead insurer, and that lead insurer remains so throughout the policy life cycle. Due to the nature of the subscription insurance market and the way such policies are structured, it is appropriate for the lead insurer to act as the sole RRE as it relates to Section 111 mandatory reporting requirements. The ability for the lead insurer to act as the sole RRE is predicated on the assumption that the lead insurer will avail themselves of all rights, requirements, and responsibilities codified in statute and further set out in regulation and within this and any other sub-regulatory guidance provided by CMS, as is from time to time amended. In any such lead reporting situation, as it relates to subscription insurance policies, CMS will assume that the lead insurer, as the sole RRE, will be responsible for all applicable reporting, recovery, and benefits coordination requirements that presently exist, regardless of the existence of any other co-insurer that may enter into a subscription arrangement or similar contract with the lead insurer.
The updated User Guide also reflects that the File Type value in the NGHP Unsolicited Response File Header Record now reads “USOL.” As announced by CMS in Version 7.0 of the User Guide earlier this year, as of July 2023 RREs may opt in to receive a monthly NGHP Unsolicited Response file for ORM records. The NGHP Unsolicited Response file will alert RREs to ORM records that were updated by another entity during the preceding month and will include the source and reason for the update and the date the record was last changed.
The User Guide is available at https://www.cms.gov/medicare/coordination-of-benefits-and-recovery/mandatory-insurer-reporting-for-non-group-health-plans/nghp-user-guide/nghp-user-guide. If you have any questions regarding the changes to the User Guide or any other Section 111 reporting issues, please do not hesitate to contact us.