On April 2, the Centers for Medicare and Medicaid Services (CMS) released an update to the Section 111 NGHP User Guide Version 7.5.
As indicated on prior Section 111 NGHP Town Hall teleconferences, CMS continues to review reporting requirements and will post any applicable updates in the form of revisions to Alerts as necessary. The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a Total Payment Obligation to Claimant (TPOC) date after April 4, 2025 (Section 6.5.1.1).
What Changed?
Most notably, the NGHP User Guide, version 7.5, now outlines the specific criteria for reporting WCMSA amounts along with other essential data.
The NGHP User Guide, Section 6.5.1.1 of Chapter III: Policy Guidance, was updated to state:
For workers’ compensation records submitted on a production file with a TPOC date on or after April 4, 2025, Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) must be reported.
CMS also updated Chapter V: Appendices to identify the fields that will be added to the Claim Input File Detail for WCMSA reporting, please refer to the appendices for the fields.
For additional technical and detailed information, please contact your Section 111 vendor or if you are a Responsible Reporting Entity (RRE), contact your assigned CMS Electronic Data Interchange (EDI) Representative. Chapter 8 of the guide provides detail on the Customer Service and Reporting Assistance for Section 111.
Ametros' prior blog update can also be referenced for further details on the submission of information related to WCMSAs being required for all records submitted with a Total Payment Obligation to Claimant (TPOC).
Upcoming 4/16 CMS Webinar
Please note CMS has a follow up Section 111 webinar scheduled on 4/16 at 2pm EST., please refer to the CMS notice providing further details, webinar link and passcode here. RRE’s are strongly encouraged to attend and sign in 10 minutes ahead of the start time. CMS will be addressing additional questions and feedback from the industry from their November webinar.
The second part of the CMS webinar update provides an update on the reporting threshold. As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Section 6.4).
Stay Updated
Read more from Ametros on CMS' latest industry updates regarding Section 111 WCMSA Reporting and an updated WCMSA Reference guide here:
- Medicare Demands to Know What is Set Aside in a Settlement by Expanding WCMSA TPOC Reporting
- A Deep Dive into the WCMSA Reference Guide v4.0 April 2024 Updates
If you have questions about ensuring WCMSA compliance post-settlement or about CMS' recent updates, please feel free to reach out to our team of experts.
