Self-Insured Claims in the CO APCD
On March 1, 2016, the Supreme Court made a decision in the Gobeille vs. Liberty Mutual case prohibiting states from mandating the submission of health care claims from ERISA-based self-insured employers. However, the Supreme Court decision does not prohibit voluntary submission of claims information from self-insured ERISA plans, and non-ERISA self-insured employers are still required to submit data according to the current CO APCD rule.
Self-insured claims represent a large proportion of processed claims in Colorado and the absence of such data in the CO APCD results in a significant gap in covered lives, thereby creating challenges to fully understanding Colorado’s health care landscape and opportunities for positive change. Self-insured employers submitting their claims information can also access reports that benchmark their performance to other payers to help them identify specific ways to save money on insurance payments and improve the health of their employees.
CIVHC and the Colorado Department of Health Care Policy and Financing (HCPF) strongly recommend ERISA-based self-insured employers to submit their data to the CO APCD. By including claims information, employers can identify ways to save costs and improve the health of their employees while enhancing health care transparency for the benefit of all Coloradans.
Learn more: Self-Insured Employer Submission FAQs
Contact us with additional questions: ColoradoAPCD@civhc.org
How to Request Your Claims Be Submitted to the CO APCD
1. Step one, Complete Opt-in Form: Submit the Voluntary Submission Opt-in Form to ColoradoAPCD@civhc.org, and we will share it with your TPA/ASO to let them know you wish to have your data submitted to the CO APCD.
2. Step two, BAA with TPA/ASO: Typically, self-insured employers have a HIPAA-compliant business associate agreement (BAA) in place with their TPA or ASO. Those agreements may already support voluntary CO APCD data submission by providing the TPA or ASO with authority to make disclosures required by law and for health oversight activities on behalf of the plans they service. In the event that the BAA does not already permit disclosure for public health or health oversight activities, such authority can be readily granted by the employer via a simple update to the permissible uses and disclosures section of the BAA. Please review your BAA or contact your TPA or ASO to ensure your agreement enables submission to the CO APCD. We have included some sample language below.
Sample BAA Language: “Business Associate may disclose PHI to the Colorado All Payer Claims Database for the public health and health oversight activities authorized by Colorado law at C.R.S. § 25.5-1-204 and the regulations promulgated thereunder.”
3. Step 3 (Optional), Complete Data Sharing Agreement with CIVHC: Although it is optional and not required by HIPAA regulations or the CO APCD Statute or Rules, CIVHC also has a Data Sharing Agreement available for voluntary data contributors that clearly identifies CIVHC’s role as the CO APCD Administrator and spells out CIVHC’s commitment to protecting and treating voluntary CO APCD data submissions in the same manner as it treats mandatory data submission. Please submit this form to CIVHC if you would like to have this agreement in place.
The above information is not intended to convey or constitute legal advice. Please consult your legal counsel with specific questions.