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09/Apr/2024

On April 1, 2024, Centers for Medicare & Medicaid Services (CMS) updated the MMSEA Section 111 Non-Group Health Plan (NGHP) User Guide version 7.5. It has been posted to the NGHP User Guide page on CMS.gov.  The NGHP User Guide version 7.5 replaces Version 7.4 which was released on January, 30, 2024.

To download the updated MMSEA Section 111 NGHP User Guide 7.5 click here.

MMSEA III- April 1, 2024 – NGHP User Guide Downloads 7.5

Updates:  There are no changes for this version

Updates:  There are no changes for this version.

Updates:   The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a TPOC date after April 4, 2025 (Section 6.5.1.1). 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).

Updates:  The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a TPOC date after April 4, 2025 (Sections 6.1, 6.4.4, and 6.5). 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).

Updates:  Beginning April 4, 2025, CMS will collect information about WCMSAs through Section 111 reporting. To support this effort, related fields have been added to the Claim Input File Detail Record; note that as the current file layout is unchanged, all the not-yet-implemented codes are marked with an asterisk (*) in the field number to distinguish them from the those in the current file layout. Once they are in effect, all the asterisks will be removed and the fields that follow them will be renumbered. Error codes related to these fields have also been added to the Claim Response File Error Code Resolution Table (Appendix A and Appendix G).

Updates:  The end-of-line character has been clarified for files using HEW software (270/271 File Translation).

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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02/Apr/2024

The Centers for Medicare & Medicaid Services (CMS) released a revised Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (“Reference Guide”) Version 4.0 on April 1, 2024. This Reference Guide replaces Version 3.9 which was released on May 15, 2023. There are a few notable changes when comparing the two Reference Guides.   

Changes in This Version 4.0 of this Guide Include the Following Changes:

  • 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). This user-friendly mechanism which allows CMS to gain potentially more MSA spending information than it has received via traditional mailing, may lead to CMS denying more future medical claims or potentially considering whether recovery of future medical payments that slipped through the cracks is viable. 
  • The CDC Life Table link was updated (10.3) – available to view here.

 

To download the new WCMSA Reference Guide v4.0 click hereThis guide reflects information compiled from all WCMSA Regional Office (RO) Memoranda issued by CMS, from information provided on the CMS website, from information provided by the Workers Compensation Review Contractor (WCRC), and from the CMS WCMSA Operating Rules. The intent of this reference guide is to consolidate and supplant all historical memoranda in a single point of reference. Please discontinue the reference of prior documents.

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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25/Mar/2024

On Tuesday April 16, 2024, Centers for Medicare & Medicaid Services (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.


 

Date:  April 16, 2024
Time:  2:00 PM EST

Webinar Link: https://cms.zoomgov.com/s/1610015349?pwd=NHcza3NhcDlCdjM0cVhENWlNcFBjZz09
Passcode:  750766

Or to connect via phone:

Conference Dial In:  1-833-568-8864
Conference Passcode:  161 001 5349


 

Additional information about the most recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients or your company, please contact Medivest or call us at 877.725.2467.

 


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26/Feb/2024

On Friday, February 23, 2024, Centers for Medicare & Medicaid Services (CMS) published an alert regarding the upcoming change to Section 111 reporting to include Workers’ Compensation Medicare Set-Aside (WCMSA) amounts for Workers’ Compensation settlements meeting the $750 threshold regardless of whether the WCMSA was submitted to CMS for approval or not.

“All MSA funding for WC settlements shall be reported regardless of whether or not an approval was previously sought from the CMS. This change will be prospective for the Total Payment Obligation to Claimant (TPOC)s on or after the implementation date. For example, records submitted on a production file with a TPOC date on or after April 4, 2025, will be subject to the new edits.”

Please note that testing of the new fields will be available as early as October 7, 2024. The full alert is available at in the Download section of the NGHP Alerts page here.

For Additional Information

Count on Medivest to help keep you up to date with the constant updates, guidance, and rule changes related to CMS’s enforcement of the MSP on a regular basis. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

 


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15/Feb/2024

CMS has announced that it is maintaining the $750 Section 111 reporting threshold and the $750 Medicare Secondary Payer statute’s (MSP) recovery thresholds for 2024. CMS’s announcement that can be found here.

The CMS notification states, “Beginning 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 responsibly for medicals.

This means that entities are not required to report, and CMS will not seek recovery on settlements, as outlined above. Please note that the liability insurance (including self-insurance) threshold does not apply to settlements for alleged ingestion, implantation, or exposure cases.

Additional information regarding the methodology used to determine the threshold is also provided at the link to the announcement.

For Additional Information

Medivest will continue to monitor news and updates from CMS, and will keep its readers up to date when important announcements are made. For questions about this chart or any other recent updates, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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31/Jan/2024

The January 18th, 2024 webinar hosted by Centers for Medicare & Medicaid Services (CMS) entitled Medicare Secondary Payer and Certain Civil Money Penalties (Non-Group Health Plan) is now available in the Download section of the What’s New page on CMS.gov. The webinar can be viewed in its entirety, or you may download the materials covered in PDF format by clicking here.   

Medivest will continue to monitor news and updates from CMS and will keep its readers up to date when important announcements are made. For questions regarding the information presented in this webinar or any other recent CMS updates, please reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467. 

 


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10/Jan/2024

CMS updated the Medicare Secondary Payer Recovery Portal (MSPRP) User Guide on January 8, 2024 to version 6.0, which outlines updated functionality and improvements to the Portal. The User Guide can be found here.

Changes of Note

Chapter 1 contains a summary of updates / changes, many of which are administrative in nature.

One change of a substantive nature is that the definition of a disputed claim has been updated (Table 15-13).

Language on the Case Creation Continued page for self-reporting a case that is non-trauma based has been updated and clarified (Table 13-3).

Also, to reduce the number of cases submitted in error, beneficiaries, insurers, and authorized representatives now have the ability to close and permanently remove a case from their account that was reported via the MSPRP in error (Sections 12.1.3 and 12.2.4).

Probably most importantly, MSPRP users can now submit any type of correspondence for BCRC or CRC cases via the MSPRP portal. A generic Submit Case Documentation action has been added to the Case Information page, along with subsequent pages used to upload and submit documents. This is extremely helpful because in the past only certain types of documents could be uploaded on the portal and otherwise, had to be faxed or mailed in with the added time and hassle of having to confirm receipt at a later date.  Now, all types of documents may be uploaded.  This will save time and will help simplify the process for any case and especially those more complex cases that have multiple defendant and/or UIM payers.

Lastly, the Letter Activity tab has been renamed Correspondence Activity and references to these screens and sections have been updated throughout the application (Section 15.1.2.13).

For Additional Information

Count on Medivest to help keep you up to date with the constant updates, guidance, and rule changes related to CMS’s enforcement of the MSP on a regular basis. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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04/Jan/2024

CMS will be hosting a webinar regarding Certain Civil Money Penalties Final Rule for NGHP Responsible Reporting Entities (RREs). The format will be opening remarks and a presentation by CMS that will include discussion of the Final Rule, the auditing process and important dates, followed by a question and answer session. RREs who would like to submit questions in advance of the webinar are encouraged to do so using the dedicated resource mailbox at Sec111CMP@cms.hhs.gov.


 

Date:    January 18, 2024
Time:    1:00 PM ET

Webinar Link:  https://cms.zoomgov.com/s/1614664558?pwd=enlySUNSSjF1UnMzUy9vRWJodWl1dz09
Passcode:        513018

Or to connect via phone:

Conference Dial In: (833) 568-8864
Conference Passcode: 161 466 4558

Important Note: This is a public webinar and there is no pre-registration needed. The webinar link should only be utilized the day of the webinar. Due to the number of expected participants, please log in at least 10 minutes prior to the start of the presentation.


 

CMS has also announced it will be hosting a webinar regarding Certain Civil Money Penalties Final Rule for GHP Responsible Reporting Entities (RREs). Information on that webinar can be found on CMS’s website.

Additional information about recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients, please contact Medivest here or call us at 877.725.2467.


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06/Dec/2023

On December 4th, 2023, Centers for Medicare & Medicaid Services (CMS) shared a new report titled Workers’ Compensation Medicare Set-Aside (WCMSA) Fiscal Year Statistics 2023. The report provides four fiscal years of data regarding Workers’ Compensation Medicare Set-Aside (WCMSA) Proposed Value and Workers’ Compensation Review Contractor Values (WCRC) from 2020 to 2023.

Takeaways

Total Submissions
Total WCMSA submissions to CMS declined steadily between CMS’ FY 2020 and FY 2022, descending from 16,517 to 13,752, a reduction of almost 17% in three years. FY 2023’s 15,743 submission count represents a reversal of that trend for the time being. This may be the result of the appearance of Section 4.3 in the WCMSA Reference Guide in 2022, in which CMS speaks about “non-submit” or “evidence-based” MSA programs, describing them as “a potential attempt to shift financial burden”.

Proposed vs Recommended
Those who decided to voluntarily submit their proposed WCMSA to CMS for review were rewarded with recommendations that were, all told, 22.95% percent higher than the proposed amount. For comparison, the average percentage difference between the submitter’s proposed MSA and CMS’ recommended MSA for CMS’ FY 2020 through FY 2022 was 13.9%. This is an increase of roughly 65% in CMS’ FY 2023 versus the prior three years’ average. Not only is the counter percentage higher, but the total recommended amount is higher. So, it’s not as if submitters have been lowballing their submissions. For those who embraced a non-submit program for fear of significantly higher MSA counters, CMS dangled no carrots in FY 2023 to encourage a return to voluntary submission.

Proposed MSAs and Total Settlement Amounts
WCMSAs submitted by the industry have, on average, consistently ranged between a proposed amount of $70,439 and $74,847 between CMS’ FY 2020 and FY 2023. Total Settlements utilizing WCMSAs over the same period have averaged between $159,579 and $171,170. Accordingly, WCMSAs constitute around 43% of the total settlement amount in which they are included (pre-CMS recommendation).

Medical vs Rx
Medical expenses with MSAs have increased steadily in recent years and CMS’ FY 2023 is no exception. CMS’ recommended total for the medical portion of submitted WCMSAs is up 13% since 2020. Conversely, Rx expenses have declined by 33%. While several factors are likely to be at play here, CMS’ use of sometimes aggressive NDCs to price drugs may be one culprit. Medivest consistently sees submitted MSAs priced using drug NDCs unavailable in the actual market, and well below market average.

The Big Question

These are statistics from those WCMSA’s submitted for approval, meaning they were written by industry-trained professionals in an attempt to match CMS’ recommended methodology. If the industry is consistent, what has changed at CMS? Also, what does this say about CMS’s position concerning non-submitted WCMSA’s that were written to Evidence-Based Medicine or other non-submit standards in light of the previously modified Section 4.3 of the WCMSA Reference Guide?

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us directly at 877.725.2467.


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On November 13, 2023, CMS hosted a previously announced webinar focused on its upcoming expansion of Total Payment Obligation of Claimant settlement data (TPOC) to be reported under the Medicare Secondary Payer statute’s (MSP) Section 111 Mandatory Insurance Reporting.

The additional TPOC settlement data to be reported specifically includes whether a WCMSA amount was established and if so, any amount above $0.00 so designated, the amount that was approved by CMS (if applicable), the period of coverage (i.e. life expectancy of the injured worker), the funding type – whether funded by lump sum or via a structured annuity (without commenting on any preference or presumptions by CMS if funded one way or another), if funded by structure, the seed amount (a type of down payment estimating the first two years of coverage plus initial surgery for any included body part(s), the anniversary deposit (when additional annuitized payments would be made), the Case Control Number (starts with a W if submitted to CMS for approval or a 0 or 1 if not submitted), and the Professional Administrator’s EIN.

The premise for including the additional WCMSA information with TPOC data is to allow CMS to flag injury related medical diagnosis codes (ICD codes) in the Medicare beneficiaries’ record called the Common Working File (CWF) with a “W” (at least for those WCMSA’s that have been approved) to assist CMS in being more efficient at denying payment for medicals that are injury related and compensated in the TPOC settlement. The Workers’ Compensation (WC) carriers or self insureds appoint Responsible Reporting Entities (RREs) to currently provide Section 111 data for both ongoing claims with Ongoing Responsibility for Medicals (ORMs) and for settlements (TPOCs). Under this expanded reporting data set, RREs would be expected to submit this information for then current Medicare beneficiaries, with testing to occur in 2024 and implementation projected to begin in early 2025 as early as January 2025. While presenter John Jenkins, CMS Health Insurance Specialist, who also presented for CMS when the addition of Section 4.3 in the Workers’ Compensation Medicare Set-Aside Reference Guide (WCMSA Reference Guide) was announced and when CMS modified that language, made it clear that this expanded reporting expectation would not extend to No Fault or liability settlements compensating for future medicals (i.e. NFMSA’s or LMSA’s), he did say it was intended to cover WCMSA TPOC information even if the WCMSA at issue was not submitted to CMS for review/approval. For example, if the WCMSA allocation report used an Evidenced Based Medicine cost projection Method or other non-submit projection method as opposed to a CMS cost projection methodology espoused under the WCMSA Reference Guide, Jenkins explained that there would still be an expectation that this additional data would be reported to CMS.

Jenkins also indicated that once the WCMSA information is reported under Section 111, notification would be sent to the Medicare beneficiary directly.

As background in describing the history of Section 111, Jenkins reminded listeners that Section 111 is part of the federal MSP statute (42 U.S.C. Section 1395y(b)(2) et seq., and that its provisions were added to the MSP pursuant to the 2007 Medicare and Medicaid SCHIP Extension Act (MMSEA)(implemented a few years later). He also pointed out that in addition to the federal MSP statute, the regulations to the MSP are found in the Code of Federal Regulation (CFR) and that 42 C.F.R. 411.46 specifically, reiterates Medicare as a secondary payer to Workers’ Compensation claims (including for both ORM and TPOC’s, and that nothing in the webinar would replace any existing requirements of Responsible Reporting Entities as to thresholds for reporting ORM or TPOC’s).

Answers to questions from the webinar audience were provided by both Steve Forry, CMS Director Division of MSP Program Operations and presenter, John Jenkins, CMS Health Insurance Specialist.

Questions regarding the webinar’s contents and the subject matter may be submitted to CMS via its dedicated Section 111 email address, s111WCMSA@cms.hhs.gov.

Take Aways

This webinar gives us a glimpse as to how CMS intends to address the EBM and other non-submit WCMSA’s that it originally referenced when it added Section 4.3 to the WCMSA Reference Guide.  How CMS will be able to require data for something that is not required by law was not elaborated on and is yet to be seen.  However, as we in the MSP industry have always understood, while the WCMSA submission process is and has always been voluntary, we always knew that if you submit for approval, you are essentially now in the CMS arena where you will be playing by its guidance/rules.  Now, even if you don’t submit a WCMSA for approval, ostensibly for your RRE to be able to complete the Mandatory Insurance Reporting under Section 111, it seems the WCMSA amount and other new data will be available for CMS to assist it in its quest to comply with the MSP and prevent Medicare from paying until the primary plan’s injury related future compensation has been exhausted.

Claimant attorneys should be made aware of this procedure at the time it is implemented so they can field questions that may come back to them by injured workers.  Likewise, adjusters handling WC claims may also get follow up calls asking for clarification and what the notification means.  Ultimately, this means that representatives for WC carriers and representatives for injured workers should solidify their methods of providing informed consent to their respective clients so that nobody is surprised when a post settlement injury related medical that is usually Medicare covered is denied.  For those who establish WCMSA’s, the solution is to bill the WCMSA, document the expenditure (with items and services priced at the respective fee schedule rate and the prescription drugs at Redbook Average Wholesale Price (AWP), and keep up with attestations to CMS on an annual basis so that once exhausted, Medicare would become primary.

What’s New?

A new coversheet is available for any Non Group Health Plan (NGHP) or agent when corresponding with the Commercial Recovery Center (CRC) and can be found here:  CRC NGHP Correspondence Cover Sheet (cms.gov)

The NGHP Appeals Quick Reference Guide was updated and is available here:  NGHP Submit Appeals Quick Reference Guide April 2023 (cms.gov)

For Additional Information

Count on Medivest to help keep you up to date with the constant updates, guidance, and rule changes related to CMS’s enforcement of the MSP on a regular basis. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.


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