The Centers for Medicare and Medicaid Services has announced that Total Payment Obligation to Claimant (TPOC) Section 111 reporting must include Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) effective April 4, 2025.  This means CMS will require workers’ compensation payers to report MSA amounts, even if $0, concurrently with settlement amounts, when the TPOC date is April 4, 2025 and later. See CMS’s February 23 Technical Alert for details.

CMS previously explained this significant expansion in a November 13, 2023 webinar (See CMS to Require Section 111 Reporting of WCMSA Amounts).

In the February alert, CMS reiterates that this new reporting requirement aims to improve coordination of benefits for Medicare beneficiaries.  Specifically, if a WCMSA is reported, then the WCMSA will be considered primary for payment before Medicare.

Notably, the WCMSA reporting requirement applies to both CMS-approved and non-approved MSAs.  The rule will be prospective only, meaning it applies to TPOC dates of April 4, 2025 and later.

To collect this data, CMS is adding new fields to the Section 111 Claim Input File. This information must be reported if the reported insurance type is workers’ compensation and the TPOC amount is greater than $0. Here is a look at the new fields:

• MSA Amount: This will be either $0 or an amount greater than $0.  If an annuity is used, then the “total payout” is reported.
• MSA Period: If the MSA amount is greater than $0, you need to enter the number of years the MSA is expected to cover the beneficiary.
• Lump Sum or Structured/Annuity Payout Indicator: If the MSA amount is greater than $0, you will enter “L” for a lump-sum MSA or “S” for a structured/annuity MSA.
• Initial Deposit Amount: If an annuity, then the MSA seed amount is reported.
• Case Control Number (CCN): If an MSA is submitted to CMS for review or is otherwise submitted to CMS post-settlement, it will be assigned a CCN.  The CCN is entered in this field, although this is optional.
• Professional Administrator EIN: If the MSA includes a professional administrator, enter the Employer Identification Number of the professional administrator here.  If a professional administrator EIN is not provided, the “case administrator” defaults to the beneficiary.  If the EIN submitted does not match a registered administrator account in the Workers Compensation Medicare Set-Aside Portal (WCMSAP), then “case administrator” will also default to the beneficiary.

CMS also provided a table of error codes if errors are identified in the above-reported information.

Testing of the new fields will be made available to Responsible Reporting Entities (RREs) beginning on October 7, 2024.

Key Takeaways

The data CMS requires to be reported is not commonly captured in payer and TPA claims systems.  Consequently, claims systems must be updated with the new fields and claims professionals will need to be trained on when, how, and what to enter into these fields.

Tower will work with our Section 111 reporting clients to provide further technical information on reporting these fields, including testing. We can also assist with capturing this data for reporting purposes.

Questions remain over what CMS will do with this data once it has it.  What if the Section 111 reporting data contradicts the CMS-approved MSA data?  If a non-CMS approved MSA exhausts prematurely (meaning the funds were insufficient to cover the number of years the MSA was to cover), will CMS step in and pay for injury-related medical care, or will they claim that it was underfunded?  If they claim that it was underfunded, does the individual have a right to challenge such a determination and how does that process work?

CMS states that this technical alert, with additional information, will be incorporated into an April 2024 version of the MMSEA Section 111 Mandatory Reporting User Guide.  We will provide further updates with the release of that document.

Please get in touch with Chief Compliance Officer Dan Anders at (888) 331-4941 or daniel.anders@towermsa.com with any questions.