Centers for Medicare and Medicaid Services (CMS) provided an “early involvement” webinar to the industry on changes to Non-Group Health Plan (NGHP) Section 111 Workers’ Compensation Total Payment Obligation to Claimant (TPOC) reporting to include Workers' Compensation Medicare Set-Aside (WCMSA) information. The presentation provided a background on Section 111 Reporting, additional information on WCMSA’s that will be collected, proposed implementation timelines and a question-and-answer session. This proposed only impacts Workers’ Compensation, it does not include No-Fault or Liability.
CMS was pro-active with its outreach to the industry on these proposed changes to gain industry insights and feedback. CMS made it clear; the webinar was focused on TPOC with added WCMSA information and not on Civil Monetary Penalties, which will be addressed in a webinar in mid-January.
The Takeaway
CMS is mandating more requirements for settling parties to make sure Medicare’s interests are considered at settlement and beyond. CMS plans to expand current Non-Group Health Plan Section 111 Reporting to mandate the inclusion of certain WCMSA information as soon as January 2025. The submission of data will include both voluntary reviewed and approved WCMSA’s as well as non-approved WCMSA, Zero MSA’s and Evidence Based Medicine allocations. All workers’ compensation TPOC’s will be reportable including those under the $25,000 CMS threshold for review and approval; however, the $750 non-reporting threshold for trauma injuries remains.
Previously, CMS did not provide a mechanism for settling parties to report how much was set aside to protect CMS in Section 111 reporting. Now, on every settlement, CMS will be able to apply a marker on a set aside amount (whether voluntary reviewed/approved or otherwise). CMS will stand to have information on WCMSA’s in 3-ways, via its existing voluntary review process, existing capture of settlement documents and, now, via Section 111 TPOC reporting.
How will the WCMSA Information be Used?
CMS will use a Code W in the Common Working File (CWF) indicating there are Medicare Set Aside (MSA) funds preventing Medicare from making payment. This will be for both WCMSA voluntarily submitted and non-submitted MSA. The beneficiary will be notified of the annual attestation and exhaustion process.
What will be Collected?
| Field Name | Description | Required |
| MSA Amount (also used if Lump Sum) | Total MSA Amount | Yes, if WC and TPOC is reported |
| MSA Period – i.e. MSA funded over 20 years | Period of coverage in years | Yes, if the MSA amount is greater than zero |
| Lump/Annuity Indicator | Is the settlement set up as a lump sum or a structure annuity | Yes, If MSA amount is greater than zero |
| Initial Deposit Amount (Seed money when funding with annuity | Initial amount deposited | Yes, if specified as a structure annuity |
| Anniversary (Annual) Deposit Amount | Amount deposited annually from annuity stream | Yes, if specified as a structured annuity |
| Case Control Number | ID from case that has been established with CMS | No |
| Professional Administrator EIN | Tax ID of Professional Administrator | No |
Response File – There were no changes proposed to the Response File Layout. Errors to the new WCMSA Information submitted will be returned as new software or hard edits to the Claim Response File. Additional details on edits will be provided in future communications.
Testing – CMS advised no special testing is planned. Notification will be provided when Responsible Reporting Entities (RRE) can begin testing and encouraged coordination with EDI Rep. Testing can be done using the Technical User Guide listed below.
Projected Timeframes for Implementation
- CMS is currently doing outreach to solicit feedback from the industry that will improve the implementation process. CMS is also allowing appropriate time for RREs to update their reporting to include the additional data fields
- Updated File Layout/Error Codes – Early 2024
- Testing Availability – Fall 2024
- Implementation – January 2025
- There is no determination yet, whether CMS will require retroactive reporting
Key Takeaways
- With the expansion of TPOC reporting, Responsible Reporting Entities will have an obligation to submit regardless of whether or not it was an MSA that was not approved/submitted to CMS.
- If there is any TPOC obligation on the claim it must be reported, regardless of the dollar value.
- WCMSA beneficiaries have more insight into the reporting and attestations that are required.
Potential implications
- CMS will have greater visibility into the Medical Allocation Amount whether submitted or non-submitted. CMS continues to improve on their coordination of benefits to identify a primary payer that includes a beneficiary that received future medical benefits in their settlement.
- There is potential for the Medicare Administrative Contractor (MAC) denying further claims as a result of a marker being placed in the Common Working File, signifying the beneficiary as primary payer with the additional responsibility of reporting MSA information.
Conclusion
In conclusion, the recent changes to Non-Group Health Plan Section 111 Workers' TPOC reporting, present a significant shift in reporting obligations for insurance professionals and attestation reporting requirements for injured workers. As outlined in the CMS webinar held on 11/13, these changes necessitate careful attention to detail and timely reporting by Responsible Reporting Entities. Ametros’ professional administration services emerge as a crucial ally in navigating this evolving landscape and making sure Medicare is properly considered from the moment of the reporting at settlement and beyond.
By taking on the responsibility of completing the reporting attestation for injured workers with WCMSAs, Ametros ensures the security of future medical funds and the Medicare trust for all parties involved. If you have any questions regarding CMS' update with changes to Non-Group Health Plan Section 111 Workers’ Compensation TPOC reporting, please contact Ametros or John Kane AIC, CMSP-F & MSCC, VP of Strategy or Jayson Gallant, VP of Strategic Partnerships directly.
Additional Resources:
- Questions regarding the WCMSA TPOC Reporting can be sent to: S111WCMSA@cms.hhs.gov
- You can also sign up using your e-mail to receive CMS notifications.
- Non-Group Health Plan Section 111 User Guides: https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting/user-guide
- Slide deck will be available within 2 weeks on CMS.gov. Recording of webinar will not be available
