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Section 111


History and Applicability

Section 111 reporting obligations began for Group Health Plans as of January 1, 2009. The purpose of the Section 111 reporting process is to enable Centers for Medicare & Medicaid Services (CMS) to pay appropriately for Medicare covered items and services furnished to Medicare beneficiaries by determining primary vs. secondary payer responsibility.

 

This reporting became necessary with the passing of the Medicare, Medicaid and SCHIP Extension Act (MMSEA) to ensure the Medicare is reimbursed for conditional payments for Medicare beneficiaries when injuries are caused other entities. Section 111 reporting is an addition to the Medicare Secondary Payer (MSP) law.

 

Who does reporting apply to?

Section 111 reporting applies to any "applicable plan" including liability insurance, no-fault insurance and workers' compensation plans. In all cases, an applicable plan provides insurance coverage or payments for medical expenses for someone who is a Medicare beneficiary. If you are responsible to report for Section 111, you are considered an RRE (Responsible Reporting Entity) and may contract with the Third-Party Administrator to file on behalf of the entity.

 

How does a RRE report to CMS?

An RRE must report to CMS using their Coordination of Benefits Contractor. RRE's are required to register on the COB Secure Website at the following link: http://www.section111.cms.hhs.gov.

 

What must be reported?

Section 111 requires claim information for Medicare beneficiaries to be reported after the insurer has assumed responsibility for medical expenses or for any type of settlement, judgment, award or other payment. Claim information which must be included on the report include:

 

​Social Security  Number, Full Name, Gender and Date of Birth of injured party

​State of venue

​Date of the incident

​Diagnosis of the injury/illness (ICD-10 codes)

​Date of the payment and total payment amount

​Description of the Illness/Injury

Attorney or Power of Attorney for the Injured Party

​Settlement information of claim

 

The reporting is sent to CMS and captures all individuals meeting the definition of an “active covered individual,” which includes those who may be Medicare-eligible and who are currently employed (or the spouse or dependent of a worker who is covered by the employee’s group health plan and who may be eligible for Medicare and for whom Medicare would be secondary payer). This reporting is performed on a quarterly basis and is ultimately an employer reporting requirement. Meritain performs this reporting on behalf of the client and requires the client's assistance to complete.

 

“Active covered individuals” would likely include the following:

 

  • Those covered in a group health plan age 45 through 64 (includes the employee and family members);
  • Those covered in a group health plan age 65 and older (assuming that they have coverage based on their own or a spouse’s current employment status; includes the employee and family members);
  • Those who have been receiving kidney dialysis or have received a kidney transplant; and
  • Those covered in a group health plan under age 45 and are known to be Medicare-entitled.

 

How often is reporting required?

Section 111 reporting is required on a quarterly basis. After the RRE has registered on the CMS website, they will be assigned a 7-day file submission time period in which they will need to file for each quarter of the year.

 

Penalties

Penalties surrounding Section 111 filing are $1,000.00 per day, per claim for each day of noncompliance.

 

This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.