CMS Updates Section 111 NGHP User Guide and WCMSA Reference Guide

April 5, 2024

woman holding CMS-Updates binder

CMS Releases Updates to MMSEA Section 111 NGHP User Guide and WCMSA Reference Guide

The Centers for Medicare and Medicaid Services (CMS) began April with updates to two of its popular user guides, the MMSEA Section 111 NGHP User Guide and the WCMSA Reference Guide.  Notably, the NGHP User Guide, version 7.5, now includes details on the requirements to report WCMSA amounts with other relevant data. These will need to be reported as of April 4, 2025.

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 IV: Technical Information with similar language.

CMS Revisions to WCMSA Reporting Fields in Chapter V: Appendices

Additionally, CMS updated Chapter V: Appendices to identify the fields that will be added to the Claim Input File Detail for WCMSA reporting:

  • Field 37 – MSA Amount: This will be either $0 or an amount greater than $0. If an annuity is used, then the “total payout” is reported.
  • Field 38 – 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.
  • Field 39 – 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.
  • Field 40 – Initial Deposit Amount: If an annuity, then the MSA seed amount is reported.
  • Field 41 – Anniversary Deposit Amount: If an annuity, then the amount of the annual payments.
  • Field 42 – 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.
  • Field 43 – Professional Administrator EIN: Enter the Employer Identification Number of the professional administrator here if there is one. If this EIN is not provided, the “case administrator” defaults to the beneficiary. If the EIN 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 provided a table of error codes for errors identified in the above-reported information.

Responsible Reporting Entities (RREs) can start testing these new fields on October 7, 2024. For further details, see the Tower article, CMS Sets Date for Start of Section 111 WCMSA Reporting.

CMS also incorporated the following notice into the NGHP User Guide:

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).

The $750 reporting threshold has been in place for several years.

CMS included minor updates to the WCMSA Reference Guide, version 4.0

Specifically, CMS added:

Instruction specific to beneficiaries has been added to encourage them to use their Medicare.gov access to the portal for the most efficient method of submitting attestations (Sections 11.1.1 and 17.5).

For further information on electronic reporting of attestations, see the above-referenced sections in the guide or the Tower article, CMS Adds Electronic Submission Option for MSA Attestations.

CMS also amended the link in Section 10.3 to reflect the most recent CDC Life Table link. The life tables are used to determine life expectancy for calculation of the MSA.

CMS Sets April 16 for Webinar on Section 111 Reporting of WCMSAs

March 27, 2024

Webinar on Section 111 Reporting of WCMSAs

Prepare for Change: CMS Webinar on Expanding Section 111 NGHP TPOC Reporting to Include WCMSA Information

The Centers for Medicare and Medicaid Services has scheduled a webinar for April 16, 2024, at 2 PM ET to provide updates on the implementation of Section 111 reporting of Workers Compensation Medicare Set-Asides (WCMSAs).  Per the March 25, 2024 announcement:

CMS will be hosting a second webinar regarding the expansion of Section 111 Non-Group Health Plan (NGHP) Total Payment Obligation to Claimant (TPOC) reporting to include Workers’ Compensation Medicare Set-Aside (WCMSA) information. After the first webinar in November, CMS received additional questions and feedback from the industry. The intent of this webinar is to ensure that RREs will be prepared for the change once implemented. With that in mind, this webinar will include a background recap, summary of technical details, updated timelines and CMP impacts. The presentation will be followed by a question and answer session. Because this expansion impacts reporting of WCMSAs, it is strongly recommended that Responsible Reporting Entities (RREs) that report Workers’ Compensation settlements attend.

There is no pre-registration for the webinar.  Full details can be found here.

As of April 4, 2025, TPOC reporting must include Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs). (See CMS Sets Date for Start of Section 111 WCMSA Reporting).

The WCMSA reporting requirement applies to both CMS-approved and non-approved MSAs.  This information must be reported if the insurance type is workers’ compensation and the TPOC amount is greater than $0. 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.

Tower will provide a post-webinar summary.  If you have any questions, please contact Dan Anders at daniel.anders@towermsa.com or 888.331.4941.

 

Premier Webinar: Easy MSA Cost Savings Through Structured Settlements

May 18, 2023

Details for June 7th Webinar on Structured Settlements.

One of the easiest ways to lower the settlement cost is through a structured Medicare Set-Aside. Not only does this reduce the payer’s cost of funding the MSA, but it also provides the injured worker a consistent stream of funds for injury-related medical care over their lifetime.

 On June 7 at 2 pm (EDT) Tower will present an informative session on structured settlements for MSAs. Tower’s Chief Compliance Officer will moderate a special guest panel from Arcadia: Alisa Hofmann, Vice President – Workers’ Compensation and Medicare Practices and Lori Vaughn, Director of Arcadia Client Programs. This hour-long webinar will show how structured MSAs can benefit all stakeholders in a settlement – the injured party, Medicare and the insurance carrier or employer.

Attendees will learn:

  • How to work with a structured settlement provider to incorporate an MSA structure into settlement.
  • The methodology CMS uses to calculate a structured MSA.
  • Rules around converting a CMS-approved lump sum MSA into a structured MSA.
  • The role of a structured settlement broker pre-settlement, during settlement negotiations and post-settlement.

A Q&A session will follow the presentation, and you can provide questions you’d like to have answered when you register. Please click the link below and register today!

Please note that there is no CEU credit offered for this webinar.

Register here.

About Alisa Hofmann:

Alisa is the Vice President of Workers’ Compensation and Medicare Practices at Arcadia Settlements Group and currently works on the Business Development team. She has been handling and overseeing Workers’ Compensation claims for almost three decades with various national carriers.  Alisa obtained her BA in Organizational Communication at Otterbein University. She maintains her adjuster licensing in many states, also holds Life, Health, and Accident Licensing, and many Insurance Accreditations. Alisa has been an active member of the National Structured Settlement Trade Association since 2019, and a member of The MSP Network where she serves on the Professional Administration and Structure-Education Committee.

About Lori Vaughn:

Lori Vaughn has 15+ years of experience in the structured settlement industry and currently oversees structured settlement programs for multiple workers’ compensation and private insurance carrier clients. She leads teams of consultants, case managers, and corporate employees, and is the primary point of contact for the corporate management team for each client. Lori obtained her BS in Kinesiology from California State University, Fresno, and her MS in Kinesiology from California Baptist University. She holds her Life, Health, and Accident licenses in many states and is a member of the National Structured Settlements Trade Association.

Premier Webinar: Zeroing in on $0 MSAs

January 25, 2023

Details for Feb 15 webinar for Medicare Set-Aside (MSA's)

A $0 MSA remains an option in some workers’ compensation case settlements, although strict criteria must be met if CMS approval is necessary.  It is essential then for claims professionals to understand this criteria as steps taken early in claims handling can sometimes be the difference between a $0 and a fully funded MSA at the time of settlement.

Over his two decades in MSP compliance, Tower’s Chief Compliance Officer, Dan Anders, has successfully obtained CMS approval on hundreds of $0 MSAs.  Please join him for a Tower Premier Webinar on Feb. 15 at 2 PM ET.

In addition to $0 MSAs, Dan will also discuss using state statutes and regulations to limit MSA amounts.

The presentation covers the following:

  • Criteria for a CMS-approved $0 MSA
  • Alternative criteria for a Non-Submit $0 MSA
  • A step-by-step guide as to how to work with Tower to obtain a $0 MSA.
  • Use of state statutes and regulations to limit the MSA amount.

A Q&A session will follow the presentation, and you can provide questions you’d like us to cover when you register. Please click the link below and register today!

Please note that there is no CEU credit offered for this webinar.

Register Here

Premier Webinar: Care, Cost & Compliance Through MSA Professional Administration

October 25, 2022

details about Tower webinar about MSA Professional Administration

We rightly invest time to draft a Medicare Set-Aside (MSA) that accurately considers future medical care and, when appropriate, obtain approval of the allocation from the Centers for Medicare and Medicaid Services (CMS).

However, we don’t always dedicate enough time to address the MSA’s post-settlement implications for the injured or ill employee. This is a mistake. The comfort level the injured employee has with how well the MSA will be funded, its administration, and what resources are available to them after the claim closes often leads to their agreement to settle.

Tower MSA Partners is pleased to present this premier webinar on Nov. 16 at 2 PM ET which will feature special guest presenter, Nicole Chappelle, Vice President of Settlement Solutions for Ametros and Dan Anders, Tower’s Chief Compliance Officer.

The presentation covers:

  • CMS rules and options around MSA administration and MSA funding
  • Self vs. professionally administered MSAs
  • A step-by-step guide to how MSA professional administration works
  • Incorporation of MSA professional administration into a settlement agreement and expectations post-settlement

A Q&A session will follow the presentation, and you can provide questions you’d like us to cover when you register. Please click the link below and register today!

Register Here

Premier Webinar: Tricks of the Trade for Successful MSA Outcomes

July 5, 2022

details about webinar on MSA outcomes

Not all Medicare Set-Asides (MSAs) are the same. There are specialty areas for unusual cases and many questions about these:

  • Criteria for successful $0 MSA approvals
  • Whether to include PQMEs, AMEs, IMEs in the MSA
  • Use of court orders to limit medical care in the MSA
  • When and how to use the MSA Amended Review process
  • Correct verbiage for treating physician statements

Claims professionals and attorneys often receive conflicting or unclear information around these topics and other matters that make not only working with the MSA but the whole settlement process, tricky.

Tower is pleased to feature our Chief Compliance Officer Dan Anders, who will share tricks of the trade at a webinar on Wednesday, July 20, at 2:00 PM ET. Dan has written and submitted thousands of MSAs to CMS for almost two decades. His unique knowledge is an asset for anyone who uses an MSA in a case settlement.

A Q&A session will follow the presentation, and you can provide questions at the time you register. Please click the link below and register today!

REGISTER HERE

Tower MSA Partners Arranges for CMS Officials to Headline WCI’s MSP Sessions

November 30, 2021

WCI Conference

When the WCI Conference invited Tower MSA Partners to produce the first day of its Medicare Secondary Payer (MSP) compliance track, Tower asked representatives from the Centers for Medicare and Medicaid Services (CMS) to kick-off a trio of MSP panels.

“It’s the 20th anniversary of CMS launching its Medicare Set-Aside (MSA) review program,” said Tower’s Chief Compliance Officer Dan Anders.  “We thought this would be a great opportunity for attendees to listen and ask questions of the key policymakers on all matters related to MSP enforcement.”

The section will start with a CMS Townhall covering such matters as the implantation of the PAID Act and how not to run afoul of CMS when submitting an MSA at 1 p.m. on Tuesday, December 14.  Anders will moderate the Townhall. Panelists appearing via video will be Deputy Director of MSP Program Operations Jackie Cipa, Director MSP Program Operations Steve Forry, and John Jenkins, Jr., Health Insurance Specialist, Division of MSP Program Operations, CMS.

Following at 2 p.m. is “Don’t Forget Medicare Conditional Payments!” moderated by Tower’s Chief Operating Officer Kristine Dudley and featuring Rasa Fumagalli, Director of MSP Compliance with Synergy Settlement Solutions and Heather Schwartz Sanderson of the Sanderson Firm.

“Conditional payment matters frequently take a backseat to Medicare Set-Asides,” Dudley said. “These experts will show you how to discharge Medicare conditional payment and Medicare Advantage plan reimbursement demands with confidence for both injured worker and payer.”

Anders returns as a panelist with Ametros General Counsel Shawn Deane and Mark Meyer, Claim Attorney for Montana State Fund, for the 3:15 p.m. session, “It’s Still Ok to Submit an MSA.” Sanderson will moderate the discussion designed to show how to balance care, cost and compliance to secure a CMS-approved MSA.

The 75th Annual WCI Conference will be held December 12-15 at the Orlando World Center Marriott.  Please see https://www.wci360.com/conference/.

Attend the Virtual MSPN Annual Conference!

August 23, 2021

MSPN Annual Conference details and registration information

The National Medicare Secondary Payer Network (MSPN) will hold its virtual MSPN Annual Conference on September 29 and 30.  With the theme of the Roaring ‘20s, the conference celebrates surviving, revamping, and emerging stronger.

MSPN is the only national MSP organization with an influential membership base of claims adjusters, insurance carriers, life care planners, Medicare Set-Aside allocators, nurses, and other medical professionals. Attorneys, professional administrators, self-insured employers, settlement planners, social workers, structured settlement brokers, and third-party administrators are other prominent members. If you’re one of those, work for a self-insured employer, or are reading this post, you should attend.

Open to non-members, the MSPN Annual Conference is designed for insurance, healthcare, financial services, and litigation professionals whose business touch MSP compliance directly or tangentially.  The conference applies for continuing education for multiple licenses and certifications in insurance, case management, legal, disability, nursing and other medical, and disability management fields.

Presented by national leaders in MSP compliance, representatives of CMS and its contractors, the annual meeting examines various aspects of Medicare Secondary Payment.  Sessions dive into Medicare Set-Asides, the recent PAID Act, MSP compliance in Liability, legislative updates, the coming Civil Monetary Penalties for incomplete or inaccurate Section 111 reporting, post-settlement overview, and other timely topics.

CMS Directors and executives from its contractors explain its conditional payment recovery reimbursement and appeals processes in separate presentations. These give you a chance to hear from the folks who make the MSP decisions that determine our compliance.

Plus, Tower’s Chief Compliance Officer and MSPN President Dan Anders (that’s me) will host a lively Fire Side chat with Jackie Cipa, Deputy Director, CMS Division of MSP Program Operations and Steve Forry, CMS Division Director for MSP Program Operations. They will share meaningful takeaways from this year’s annual meeting and highlight emergent issues in the MSP universe.

You can find plenty of information on MSPN’s website about the conference along with early registration fee discounts (Available before Sept. 1).  Remember, the conference is virtual, September 29 and 30 (As the conference is virtual, all sessions will be recorded and may be viewed post the set conference days).  Don’t delay! Register today!

If you have questions about the MSPN or its annual meeting, do not hesitate to contact me at Daniel.anders@towermsa.com or (888) 331-4941.

PREMIER WEBINAR: Learn How to Take MSA Legacy Claims to Settlement

May 27, 2021

Portrait of Hany Abdelsayed with details about Legacy Claims to settlement webinar

Trying to bring more of your legacy claims to settlement? 

This could be the most valuable webinar you’ll ever attend!

Do you have aging claims that continue to draw down on indemnity and medical reserves?  Perhaps there is no ongoing medical, but the injured worker was unwilling to settle. Or maybe a claimant is willing to settle, but a prior MSA placed settlement out of reach.

These legacy claims can be settled with a program that aggressively addresses Medicare Set-Aside (MSA) cost drivers and mobilizes a settlement team that paves the way to claim closure–without increasing your adjuster’s workload.

You are invited to join Hany Abdelsayed, Tower’s expert in legacy claims settlement initiatives, for a fast-paced webinar on Thursday, June 24 at 2 p.m. Eastern.  You’ll learn about:

  • Recognizing legacy claims both obvious and hidden
  • Identifying MSA cost drivers, which impede settlement
  • Clinical interventions that contain MSA costs
  • Settlement partners who clear the path to settlement/claim closure

A Q&A session will follow the presentation.  Please click the link below and register today!

Register now

 

 

CMS Section 111 Mandatory Insurer Reporting Webinar Recap

April 7, 2021

man on keyboard for Section 111 Mandatory Insurer Reporting

Leaders from the Centers for Medicaid and Medicare Services (CMS) Division of MSP Program Operations, Commercial Repayment Center (CRC), and Benefits Coordination and Recovery Center (BCRC) held an April 1 webinar on the intersection of the BCRC and CRC in Section 111 Mandatory Insurer Reporting and the resolution of Medicare conditional payments.

While mostly a Q&A format, the webinar unveiled a new CMS/BCRC policy for reporting partial settlement of medical when Ongoing Responsibility for Medical (ORM) ends for certain diagnoses and continues for others. Set to rollout in June, the new reporting policy provides for three scenarios:

  • Partial settlement of medical prior to initial reporting

Scenario:  Claimant is identified as a Medicare beneficiary which triggers the requirement to report ORM and/or Total Payment Obligation to the Claimant (TPOC) through the Section 111 reporting process.  Both ORM and TPOC are for the same insurance type, policy, and claim number.  The only difference is the accepted and denied diagnoses on the claim.  The parties agree to a partial settlement for the denied diagnoses and leave the accepted diagnoses open on the claim.

Problem:  How to report a partial settlement of the denied diagnoses and still report ORM for the accepted diagnoses.

 CMS Solution:  CMS’s solution is to submit two add records. Specifically, one record will be added for ORM that will describe all of the diagnoses that have been accepted for ORM.  ORM will be ‘Y’ with no TPOC date or amounts.  A second record will be added for TPOC which will describe all of the denied diagnoses that are being settled.  ORM will be ‘N’ with a TPOC date and amount.

  • Partial settlement of medical post initial reporting

Scenario:  A claim with multiple diagnoses was reported for ORM through the Section 111 Mandatory Insurer Reporting process.  The parties agree to a settlement for certain diagnoses while keeping ORM open for other diagnoses.

Problem:  How to report a partial settlement for certain diagnoses while keeping ORM open for the non-settled diagnoses.

CMS Solution:  CMS’s solution is to submit one update record and one add record.  The update record will remove the diagnoses that are subject to the partial settlement and keep the diagnoses codes where ORM continues.  Then, an add record with the TPOC date, amount and diagnoses codes that are subject to the partial settlement will be submitted.  ORM will remain “N” in the add record.

  • Partial ORM closure with no settlement

Scenario:  Acceptance of ORM is initially reported though the Section 111 Mandatory Insurer Reporting process with multiple diagnoses.  Subsequent to this initial report, there is a basis to terminate one or more of the initially accepted diagnoses, but not all of the diagnoses.  This is not a situation where a partial settlement has occurred, rather there is a basis to terminate one or more diagnoses absent a settlement.  For example, a claimant’s cardiac condition was exacerbated as a result of a fall and the medical providers confirm resolution of the exacerbation. While the carrier continues to accept the orthopedic condition, the ORM can end for the cardiac diagnosis.

Problem:  How to end ORM for one or more diagnoses while keeping it open for other diagnoses.

CMS Solution:  CMS’s solution is to send an update record that removes the diagnosis or diagnoses where ORM has ended. In this situation a TPOC date is not submitted, rather this is only submitted when ORM is completely terminated for all diagnoses.

The purpose behind these new policies is to improve coordination of benefits such that a Medicare beneficiary’s medical care is not denied when unrelated to a claim and prevent the recovery contractors from attempting to seek reimbursement for Medicare payments unrelated to a claim.

While we thank CMS and the BCRC for identifying solutions to the above reporting problems, we believe RREs may face some technical challenges in the ability to, for example, report two add records on the same claim.  We await issuance of the formal policy from CMS and will review how this policy change can best be incorporated into the Section 111 reporting process.

In addition to announcing the new reporting policy, CMS and the contractors provided the following advice:

Respond to correct contractor – Carefully review the correspondence and make sure to respond to the contractor that sent the letter, whether it’s to obtain further information, dispute/appeal charges, or to make payment.

As a reminder, CMS noted, the BCRC is generally recovering conditional payments when the identified debtor is the Medicare beneficiary while the CRC is recovering conditional payments when the insurer/WC carrier is the identified debtor.

CMS provided the following guidance regarding key timeframes:

  • Interest accrues from the date of the demand letter and is assessed on debt if not resolved within 60 days.
    • When CMS issues a demand letter directly to the applicable plan, the applicable plan has formal administrative appeal rights.
    • The applicable plan has 120 days from the date the applicable plan receives the demand letter to file a redetermination (first level of appeal). Interest will still accrue during this time.
    • If the appeal is not filed within 120 days, and “good cause” for untimely filing is not provided, the appeal will be dismissed.
    • Failure to resolve the debt will result in referral to treasury at 180 days.

Note:  When you are appealing to the ALJ please be sure to cc the CRC so that they can appropriately place a hold on a case so that it is not referred to treasury while the appeal is in process.

During the Q&A portion of the webinar CMS and its contractors addressed varied questions; some are summarized below:

  • What can be done if we cannot obtain a Social Security number from the claimant? CMS advised them to document their efforts at obtaining the SSN.  It was noted CMS has model language found on the CMS website which can be used to document claimant’s refusal to provide SSN.
  • In response to a question concerning the many charges found on conditional payment notices and demands that are unrelated to the injury, CMS/CRC acknowledged that it is not a perfect process. The CRC explained that when conditional payment information is requested what is sent to the requestor may have only been produced through an automated search of charges related to the injury.  CRC did advise that when it comes to actual issuance of a demand that there is a human validating process.
  • In response to a question concerning why in response to a dispute of a Conditional Payment Notice, one might receive another CPN with new charges, the CRC explained that this is the result of the system constantly reviewing for additional charges deemed related to the injury.
  • There were several questions regarding problems with the CRC recognizing out-of-pocket reimbursements to claimants in a no-fault/med-pay claim as counting towards the exhaustion of the no-fault maximum amount. CRC’s response was to advise entities to provide plan documents and proof of payment to the claimant along with a reason for the payment.  Its leader said, “We are aware that no-fault payors have run into problems with CRC rejecting out-of-pocket expenses as included within the no-fault exhaustion amount.”

If you have any questions, please contact Tower’s Chief Compliance Officer, Dan Anders, at daniel.anders@towermsa.com or 888.331.4941.

Related prior posts:

CMS RELEASES TECHNICAL UPDATES TO SECTION 111 USER GUIDE