CMS Publishes NGHP Section 111 User Guide Version 7.1

by F. Fairchok

The Centers for Medicare & Medicaid Services (CMS) published an update to the Non-Group Health Plan (NGHP) Section 111 Reporting User Guide on April 24, 2023. This updated User Guide, Version 7.1, contains changes relating to subscription insurance policies and upcoming functionality around the Unsolicited Response File.

Subscription Insurance Policies

For subscription insurance policies, CMS has added language to the User Guide stating that the lead insurer will act as the sole Responsible Reporting Entity (RRE) and be responsible for all reporting, recovery, and benefits coordination requirements regardless of the existence of any other insurer. This addition can be found in Chapter III, section 6.1.13, and is included 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.”

Unsolicited Response File Changes

The “Summary of Version 7.1 Updates” page in Chapter V states:

“The File Type value in the NGHP Unsolicited Response File Header Record now reads “USOL” (Appendix F).” Version 7.0 of the User Guide listed the file type as “USO.”

While the above is the only noted change in the update summary, we found additional changes have been made to Table F-2: NGHP Unsolicited Response File Detail Record. The following fields have been removed from the file structure and replaced with 39 characters of filler space:

• • Policy Holder’s First Name (Field 21)
  • Policy Holder’s Last Name (Field 22)
  • Policy Holder’s SSN (Field 23)

Commentary

CMS continues to make updates to the NGHP Unsolicited Response File process, which we expect to go into production in July 2023.  For RREs who intend to receive and process this file, we advise that they review changes to table F-2 closely since CMS did not include them in their summary of updates at the beginning of Chapter V. As we are three months out from this file going into production, there may be additional changes forthcoming along with another NGHP User Guide update if that occurs. For more information on the functionality of this file, please see our article about the January 9 User Guide 7.0 update.

If you have questions regarding this article and/or any changes made in version 7.1 of the User Guide, please don’t hesitate to email us at [email protected]. If you are looking for further guidance on Section 111 reporting compliance, our experienced Medicare Secondary Payer Reporting services team can collaborate with you to customize the compliance experience to meet your unique needs and requirements. Contact us today to learn more.