Attachment A – Definitions and Reporting Responsibilities
Supporting Document for PRA Package for Medicare Secondary Payer Reporting Responsibilities for Section III 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 Administration (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 GHP’s (as defined at 42 U.S.C. 1395y(b)(I)(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 GHP’s. 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 GHP’s
- TPA’s for GHP’s
- Employers with self-insured and self-administered GHP’s
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.
Attachment A – (Continued)
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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.
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 42U.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
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 judgment, award, or other payment to satisfy an alleged claim (including any deductible or co-pay on a liability insurance, no-fault insurance, or workers’ compensation law or plan) for a business, trade or profession. See also 42 C.F.R. 411.50.
