CMS Issues Alert for Expansion of Section 111 NGHP Reporting to Include Data for WCMSA Arrangements

by M. Heberling

The Centers for Medicare & Medicaid Services (CMS) issued a Technical Alert on February 23, 2024, related to changes to worker’s compensation Section 111 Reporting for Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs). The alert provided notification that the Total Payment Obligation to Claimant (TPOC) reporting process will be expanded to include reporting of Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs), with an effective date of April 4, 2025.

Expanded TPOC Reporting Is Prospective and Includes All WCMSAs
Following the effective date, the expanded Section 111 reporting process will require RREs to report WCMSA information on all Workers’ Compensation (WC) claims involving settlement with a Medicare beneficiary. This includes all WCMSAs regardless of whether approval was sought and obtained from CMS. CMS specified that the change will be prospective for TPOCs that are on or after the effective date of April 4, 2025.

Details of Expanded TPOC Reporting
New fields are being added to the Section 111 Claim Input File to collect the expanded TPOC reporting information and existing fields will be renumbered as appropriate. The new fields are intended to capture the following information on WCMSAs:

      1. MSA Amount – Field 37
      2. MSA Period – Field 38
      3. Lump Sum or Structured/Annuity Payout Indicator – Field 39
      4. Initial Deposit Amount – Field 40
      5. Anniversary (Annual) Deposit Amount – Field 41
      6. Case Control Number – Field 42
      7. Professional Administration EIN – Field 43

The alert includes detailed descriptions on what to report in each of these fields, as well as technical information on how to report. Notably, errors pertaining to the reporting of this information will be returned as new “CW” errors in the existing Claim Response File. There will be 12 new errors codes from CW01 to CW12 that will identify inaccurate/incomplete reporting in each of the new fields.

New NGHP User Guide Upcoming
CMS indicated that information in the alert will be incorporated and published in an upcoming April 2024 version of the MMSEA Section 111 Medicare Secondary Payer Mandatory Reporting Liability Insurance (Including Self-Insurance), No Fault Insurance, and Workers’ Compensation User Guide.

Thoughts and Takeaways
During the most recent CMS webinar regarding these upcoming changes on November 13, 2023, CMS clarified that submission of the WCMSA remains a voluntary process. This alert further demonstrates that CMS understands that submission is voluntary because the TPOC reporting process is the same for all WCMSAs, even those that were not submitted for approval by CMS. Moreover, CMS will be tracking cases that do not meet their current review threshold. CMS has routinely indicated that thresholds are workload driven and do not exempt parties from considering Medicare’s interests. As such, below-threshold MSAs should be considered as part of settlements.

With this expanded reporting, CMS’ focus is on capturing the MSA amount, the details related to how it is being funded, and information on the administration component. This alert should therefore not affect decision making about whether to engage with the voluntary CMS’ review process. However, it may be a good time to start thinking about whether enough is being done to confirm and document the appropriate exhaustion of WCMSAs and/or examine your policies related to protecting Medicare’s interests in settlements that do not meet the current eligibility threshold for CMS’ voluntary review program.

If you have any questions related to Section 111 reporting, including the upcoming changes to the TPOC reporting process, please reach out to our Settlement Consulting team at [email protected].