Submission of Annual Enrollment and Contributions

The Patient Protection and Affordable Care Act (Affordable Care Act) fundamentally changed the way health insurance was regulated in the United States. Reforms included ambitious changes to ensure that consumers have multiple health insurance coverage options, that states have flexibility in their markets, and that issuers and employers have guidance regarding new insurance underwriting practices, particularly as they apply to the individual and small group markets.  The Transitional Reinsurance Program was established by Section 1341 of the Affordable Care Act (ACA) to help stabilize premiums in the individual market. The contributions are required from 2014 through 2016 and will be used to make reinsurance payments to health insurers that cover high-risk individuals in the individual market.

Overview of the Transitional Reinsurance Program

Reinsurance contributions are required for the 2014, 2015 and 2016 benefit years. The program is funded by contributions collected from health insurance issuers and certain-self insured group health plans to cover costs for high-cost individuals enrolled in non-grandfathered, reinsurance-eligible individual market plans.

HHS will collect from all contributing entities, and certain self-insured group health plans. The reinsurance contribution amounts apply for the applicable benefit year, and contribution amounts are payments made to the U.S. Treasury in the last quarter of the calendar year.

The $63 per capita reinsurance contribution for the 2014 benefit year will be collected in two installments:

• $52.50 in January 2015
• $10.50 late in the fourth quarter of 2015

Which entity is liable for making the reinsurance payments? 

The Affordable Care Act imposes the Transitional Reinsurance Program Fee and requires that health insurance issuers and third party administrators, on behalf of group health plans, make payments to an applicable reinsurance entity, if they provide major medical coverage. Excluded from the obligation to make reinsurance contributions for 2015 and 2016 are self-insured, self-administered group health plans. (ACA § 1341; Preamble Notice of Benefit and Payment Parameters Final Rule, 78 Fed. Reg. p. 15455.) The final rule defines “contributing entity” as a health insurance issuer or a self-insured group health plan which is ultimately responsible for the reinsurance contribution even if the group health plan chooses to use a third party administrator or administrative services-only contractor to make the reinsurance contributions. (45 C.F.R. § 153.20.)

With respect to insured plans, the insurer is responsible for making the reinsurance contribution. For self-funded group health plans, the plan is liable for the fee, but may utilize a TPA’s services.
A TPA or Administrative Services Only (ASO) contractor may be utilized to transfer reinsurance contributions on behalf of a self-funded group health plan, at that plan’s discretion.

Contributions are to be determined based on a flat per capita amount based on all covered lives (participants and dependents) in the covered plan. The final rule also emphasizes that reinsurance contribution amounts must reflect a health insurance issuer’s “fully insured commercial book of business for all major medical products.” (ACA § 1341(b)(3)(B)(i); Preamble Notice of Benefit and Payment Parameters Final Rule, 78 Fed. Reg. p. 15456)

Calculation of Reinsurance Contribution Amount and Timeframe for Collections

Specifics regarding the actual calculation of the contribution rate are set forth in the final regulations issued on March 11, 2013. Under the regulations, a “Covered Plan’s” contribution is calculated by multiplying “the average number of “covered lives” of reinsurance contribution enrollees during the “benefit year” (defined as calendar years 2014, 2015 and 2016) times the “national contribution rate” as set annually by HHS. For self-funded plans, “covered lives” generally means the participants and dependents covered by the plan.

The final rule outlined several methods that health insurance issuers and self-insured group health plans may use to determine the number of covered lives of reinsurance contribution enrollees in order to provide HHS with an annual enrollment count. These methods are:

(i) Actual count method, in which the plan sponsor adds the sum of lives covered for each day of the plan year and divides that sum by the number of days in the plan year;

(ii) Snapshot count method, in which the plan sponsor adds the total number of lives covered on equal numbers of days in each quarter of the plan year and then divides the total by the number of days on which the count was made;

(iii) Snapshot factor method, in which the plan sponsor follows the same procedure as the snapshot count method, but counts participants instead of covered lives and each participant who has elected some level of coverage other than self-only coverage counts as 2.35 participants; or

(iv) Form 5500 method, in which a plan sponsor of a plan providing coverage for employees and dependents adds together the number of participants at the beginning of the plan year and the end of the plan year (as both numbers are reported on the Form 5500). Note that if a plan sponsor is using the Form 5500 method for a plan that provides solely employee-only coverage, the sponsor adds the number of participants at the beginning of the year and at the end of the year and then divides by two.

(v) Member months method or State form method (use data from the NAIC Supplemental Health exhibit or similar data from other state forms) This method cannot be used by self-funded plans. (45 C.F.R. § 153.405(d)-(e); Preamble Notice of Benefit and Payment Parameters Final Rule, 78 Fed. Reg. p. 15462-63)

Providing Enrollment Data

Enrollment data must be provided to HHS by November 15 of the benefit year with calculation based on January through September data. HHS will notify the Covered Plan after receiving the data of the amount of the contribution for the year.

HHS will notify each contributing entity of its contribution amounts within 15 days from the submission of enrollment or by December 15, whichever is later. The contributing entity then has 30 days after receiving notification from HHS to remit contributions. (45 C.F.R. § 153.400(a))

Single Plans and Excepted Benefits: In order to prevent the double-counting of covered lives with respect to plan sponsors that provide multiple, self-insured major medical coverage to the same covered lives through multiple plans (e.g., a separate medical surgical benefit plan and a separate mental health plan), plans may be aggregated and treated as a single plan in computing the reinsurance contribution amount. Enrollees in plans that provide “excepted benefits” (e.g., stand alone dental or vision benefits) or plans that only provide prescription drug coverage are not counted for purposes of calculating the reinsurance contribution amount.

Expense of the Plan: The required contributions are recognized by the Department of Labor as a permissible expense of the group health plan making the contribution. Generally, insurers and sponsors of self-insured group health plans may treat the contributions as ordinary and necessary business expenses, subject to any applicable disallowances or limitations under the Internal Revenue Code.

Establishing the Contribution Amounts for the Transitional Reinsurance Program Fee

The contribution amounts are calculated by multiplying a contributing entity’s annual enrollment count by the annual per covered life contribution rate:

2014 Annual Enrollment Count x $63.00 (2014 Annual Per Covered Life Contribution Rate) = 2014 Annual Contribution Amount

Various methods can be used to determine the annual enrollment count (See 45 CFR 153.405(d) through (g))

Administration through Pay.Gov: HHS released on May 23, 2014, a streamlined process for collection of the reinsurance contributions under the Transitional Reinsurance Program Fee.  HHS will administer the reinsurance program’s collection of reinsurance funds from health insurance issuers and self-insured group health plans through pay.gov. HHS will collect and pay out reinsurance funds annually.  (45 C.F.R. §§ 153.400(a), 153.240(b)(1); Preamble Notice of Benefit and Payment Parameters Final Rule, 78 Fed. Reg. p. 15461)

Under the program, a contributing entity, or a third-party administrator on behalf of the contributing entity, can complete all required steps for the reinsurance contribution progress at www.Pay.gov:Registration.

• Pay.gov offers simple way for contributing entities to register, for submission of the annual enrollment count data, and remittance of contributions.
• Pay.gov is a secure, web-based application owned by the Federal Government
• Pay.gov allows external parties to submit forms online and make online payments to government agencies.

Contributing entities will be notified of the contribution amount owed and when to make contributions.

Entities already registered on Pay.gov do not need a new account to carry out the reinsurance contribution submission process.

Registration and Submission of the Annual Enrollment Count and Remittance of Contributions: www.Pay.Gov

Overview of the Contribution Submission Process

The entity must file a form in order to begin making payments. A form will be available via  www.pay.gov where a contributing entity or a TPA on its behalf, will provide basic company and contact information, and the annual enrollment count for the applicable benefit year no later than November 15, 2014. The form will auto-calculate the contribution amounts. To complete the submission, entities will also submit payment information and schedule a payment date for remittance of the contributions. Pay.gov provides a “one-stop” approach to complete the reinsurance contributions process.

CMS offers training on this process through https://www.regtap.info

Utilizing the Federal Government Web-based Payment System to Pay the TRP

• Pay.gov offers a simplified method for contributing entities to register, submit their annual enrollment count, be notified of the contribution amount owed and remit contributions
• Pay.gov is a secure, web-based application owned by the Federal Government
• Pay.gov allows external parties to submit forms online and make online payments to government agencies.

Registration:

To successfully complete the reinsurance contribution process, contributing entities, or TPAs and ASOs must:

Register on Pay.gov
Create a User profile containing both user data and the user’s company data (both are required).
Registration Data will be used to pre-populate the Form. Careful attention should be given to the following:
Contact 1 for Submission: User’s name, e-mail and phone number within the Pay.gov profile will pre-populate the Form as Contact 1 for submission.
Legal Business Name (LBN): The company name within the Pay.gov profile will pre-populate the Form as “Legal Business Name (LBN)”
Billing Address: The company address within the Pay.gov profile will pre-populate the Form as “Billing Address”
Special Notes: The TPA or ASO contractor should create ONLY one Pay.gov account for submitting the enrollment count and contribution on behalf of one or more contributing entities.
Access the “ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form”
Complete the Form (which includes entering the annual enrollment count)
Upload supporting documentation

If a TPA or ASO is reporting the annual enrollment and making contributions on behalf of the contributing entity, the contributing entity does not need to register.

Schedule Payments for Reinsurance Contributions:

Contributing entities must also schedule payments for calculated reinsurance contributions. There are two separate deadlines for submitting portions of the full annual reinsurance contribution amount:

First collection deadline is January 15, 2015
Second collection deadline is Nov. 15, 2015
An entity that chooses to make a combined collection must submit the contribution on January 15, 2015.

The Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form on Pay.gov requires the following:

Basic company and contact information
Annual enrollment count
Upload supporting documentation (specific information on the annual enrollment count for each contributing entity represented on the form)
Payment information and payment date

Once Enrolled: Payment Is Initiated:

Once the payee has enrolled into the account and uploaded the count, the payment form will auto-calculate the contribution amount.
An Automated Clearing House (ACH) process via Pay.gov is the only vehicle being accepted for reinsurance contributions payment for the 2014 benefit year.

Note that HHS does not regulate who may submit the reinsurance contribution on behalf of the contributing entity.

The responsibility to make reinsurance contributions lies with the contributing entity, and the decision to delegate the function of submitting the reinsurance contribution is with the contributing entity.

A TPA or ASO contractor may perform this function if requested. A TPA’s or ASO contractor’s obligation to do so would be a function of the arrangement between the TPA or ASO contractor and the contributing entity and applicable state law.

Penalties?

Payment of the reinsurance contribution payment is considered to be a debt owed to the Federal government. Therefore, pursuant to 45 CFR 156.1215(c), any amount owed by an issuer and its affiliates for reinsurance is a determination of a debt and will be subject to the Federal debt collection rules. Additionally, reinsurance contributions are considered Federal funds that would be subject to the False Claims Act.

Important Key Deadlines for the 2014 Benefit Year

Submit Annual Enrollment Count –No later than November 15, 2014
Remit First Contribution Amount—No later than January 15, 2015 in the amount of $52.50 per covered life
Remit Second Contribution Amount—No later than the Fourth Quarter of 2015 in the amount of $10.50 per covered life.
Total remitted for covered life $63.00

Published by Society of Professional Benefit Administrators