CMS releases Section 111 NGHP User Guide (Version 7.1, April 24, 2023)

By Mark Popolizio, J.D., Jeremy Farquhar

April 25, 2023 / 3 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 7.1, April 24, 2023) regarding Section 111 reporting related to non-group health plans (liability, no-fault and workers’ compensation).

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As usual, CMS lists the new updates in the beginning of each User Guide chapter in a “Summary” page. Reviewing these pages indicates that updates were made to Chapter III (Policy Guidance) and Chapter V (Appendices). Overall, these changes are relatively limited in scope, but they provide both some necessary policy guidance, in relation to reporting responsibility for Subscription Insurance Policies, as well as a minor technical clarification regarding CMS’s new NGHP Unsolicited Response File formatting.

Chapter III Updates

Here, CMS’s summary describes the changes as follows: “To clarify who bears reporting and other responsibilities for Subscription Insurance Policies, a new section has been added (Section 6.1.13).”^[1]

Within Section 6.1.13, CMS defines Subscription Insurance Policies as those in which “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.”^[2] The agency further explains that these subscription policy scenarios typically involve the designation of a “lead insurer” that will take on responsibility for “various administrative and business purposes.”^[3] In these subscription policy scenarios, there have been some longstanding questions as to which entity or entities would be responsible for any associated Section 111 reporting requirements and, with this new addition to their NGHP User Guide, CMS has now provided some guidance.

To that end, CMS, as part of the new User Guide updates, states that the entity designated as the “lead insurer” would be considered the RRE and that entity would hold the sole reporting responsibility in these subscription policy scenarios.^[4] CMS has indicated 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.”^[5] While these subscription insurance policies represent a relatively small segment of the NGHP Section 111 reporting population, this is some important clarification which will likely be well received by insurers offering these types of policies.

Chapter V Updates

As for the Chapter V updates, CMS’s summary states that “[t]he File Type value in the NGHP Unsolicited Response File Header Record now reads ’USOL’ (Appendix F).”^[6]This references a minor correction to a static value which will be returned via Field 3 of the Header Record within the new NGHP Unsolicited Response File slated for implementation by CMS in July.^[7] Previously, in Version 7.0 of CMS’s NGHP User Guide, the File Type value had been published as ‘USO’ and CMS have now corrected that to read ‘USOL’. Entities that expect to opt into the new Unsolicited Response File process, that intend to implement logic to automate the intake of the data from the new file, will need to adjust accordingly. For more information on CMS’s recently announced NGHP Unsolicited File Response process, see the authors’ prior article.

Questions?

Please do not hesitate to contact the authors if you have any questions.

[1] See, CMS’s Section 111 NGHP User Guide, Chapter III (Version 7.1, April 24, 2023), Chapter 1.

[2] See, CMS’s Section 111 NGHP User Guide, Chapter III (Version 7.1, April 24, 2023), Section 6.1.13.

[3] See, CMS’s Section 111 NGHP User Guide, Chapter III (Version 7.1, April 24, 2023), Section 6.1.13.

[4] See, CMS’s Section 111 NGHP User Guide, Chapter III (Version 7.1, April 24, 2023), Section 6.1.13.

[5] See, CMS’s Section 111 NGHP User Guide, Chapter III (Version 7.1, April 24, 2023), Section 6.1.13.

[6] See, CMS’s Section 111 NGHP User Guide, Chapter III (Version 7.1, April 24, 2023), Chapter 1.

[7] See, CMS’s Section 111 NGHP User Guide, Chapter V (Version 7.1, April 24, 2023), Appendix F.