Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: November 13, 2014

Program Area: Reinsurance-Contributions (RIC)

Question: What is the difference between the Reporting Entity and Contributing Entity?

Answer: Applicable to All Reinsurance Contributions Benefit Years: A Reporting Entity is the organization completing the steps for the reinsurance contribution submission process on Pay.gov. The Reporting Entity can be the Contributing Entity, or a third party on behalf of a Contributing Entity. A Contributing Entity means a health insurance issuer and for the 2014 benefit year, a self-insured group health plan (including a group health plan that is partially self-insured and partially insured, where the health insurance coverage does not constitute major medical coverage), whether or not it uses a Third Party Administrator (TPA); and for the 2015 and 2016 benefit years, a self-insured group health plan (including a group health plan that is partially self-insured and partially insured, where the health insurance coverage does not constitute major medical coverage) that uses a TPA in connection with claims processing or adjudication (including the management of internal appeals) or plan enrollment for services other than for pharmacy benefits or excepted benefits within the meaning of section 2791(c) of the PHS Act. Notwithstanding the foregoing, a self-insured group health plan that uses an unrelated third party to obtain provider network and related claim repricing services, or uses an unrelated third party for up to five (5) percent of claims processing or adjudication or plan enrollment, will not be deemed to use a TPA, based on either the number of transactions processed by the third party, or the value of the claims processing and adjudication and plan enrollment services provided by the third party. A self-insured group health plan that is a contributing entity is responsible for the reinsurance contributions, although it may elect to use a third party administrator or administrative services-only contractor for transfer of the reinsurance contributions. See 45 CFR 153.20 for more details on the definition of 'Contributing Entity'.

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