A Busy Week for CMS: Medicare Set-Aside Reporting Webinar and Updates to NGHP User Guide and WCMSA Reference Guide

Over the last couple of days, the Centers for Medicare & Medicaid Services (CMS) has been notably active, issuing several updates impacting Medicare Secondary Payer (MSP) compliance. On Monday, CMS published updates to the MMSEA Section 111 NGHP User Guide (Version 8.4) and the WCMSA Reference Guide (Version 4.5), and on Wednesday CMS hosted a webinar addressing Workers’ Compensation Medicare Set-Aside (WCMSA) reporting. Here are the major takeaways from each event:

April 15th WCMSA Reporting Webinar

CMS began the webinar by reiterating the reasons for requiring WCMSA information as part of Section 111 Total Payment Obligation to Claimant (TPOC) reporting. In summary, CMS wants to ensure it is not paying for injury-related, Medicare-covered expenses when a WCMSA has been established.  With the rise of non-submit WCMSAs, CMS can capture this information to document the Common Working File and prevent cost shifting adding transparency to this process.

CMS also discussed multiple reporting examples and had a question-and-answer period.  Highlights of this session include the following:

1.       Professional Administration - Although the professional administration EIN is not described as mandatory because most WCMSAs are self-administered, CMS noted that this field must be treated as required if there is a professional administrator.  CMS noted that it is adjusting system logic and the User Guide to mitigate this issue, but it cannot convert the field to required “without other adverse impacts on the RRE community.”

2.       Reporting Prior to WCMSA Voluntary Approval  CMS again reiterated that if a WCMSA has been submitted as part of the voluntary review process and a WCMSA TPOC is reported prior to final approval, this will have the effect of preventing further review of the WCMSA by CMS and the WCMSA will be treated as a non-submit. 

3.       WCMSA Funding - CMS noted that if a WCMSA is approved by CMS and lump sum funding is noted on submission, it must be reported via Section 111 as a lump sum even if the parties later agree to structure the WCMSA.  Conversely, this would also be the case if the funding shifted from a structure to a lump sum.  CMS stated that a change of funding would need to be formally requested to make these updates in the system. 

4.       WCMSA Value - For CMS approved WCMSAs, CMS required the WCMSA amount to match the CMS determination.  Failure to do so would convert the WCMSA to a non-submit WCMSA.  CMS now is not including cents in this value and has added a “value tolerance” for numbers reported close to the original WCMSA amount.

CMS answered several questions surrounding multiple injuries, multiple RREs and various TPOC scenarios.  Because some of these answers were unclear or dependent on fact patterns presented, deference to the new NGHP User Guide, as outlined below is recommended. 

April 13th NGHP User Guide Update

CMS’ NGHP User Guide update touches upon several significant reporting obligations, namely TPOC and Ongoing Responsibility for Medicals (ORM) reporting.

With respect to TPOC, CMS added the following example into the User Guide:

Example: The parties to a workers’ compensation case execute an agreement regarding the claim on 01/20/2026. The state requires the workers’ compensation commission to approve the final settlement details and said approval occurs on 02/05/2026. The TPOC date in this situation would be 02/05/2026 because it is the later of the date the agreement was fully executed and the date the court or commission approved the agreement.

This example is consistent with CMS’ historical definition of TPOC Date. In instances where court approval of a settlement is required, CMS has consistently instructed Responsible Reporting Entities (RREs) to report the date of the court approval. This example is, however, a helpful illustration to include within the User Guide. In a similar vein, the User Guide now also confirms that the timeliness of Section 111 reporting will be based upon the date of court approval—not just the date of the signed settlement paperwork—if applicable (Section 6.5.1.2).

With respect to ORM, CMS added the following bolded language to the criteria for ORM Termination:

Where the insurer’s responsibility for ORM has been terminated per the terms of the pertinent insurance contract, such as maximum coverage benefits, or any other reason that is not prohibited by the terms of the insurance contract or applicable state or federal law.

Note: An insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.

This modification demonstrates that CMS is attempting to broaden the bases for ORM Termination. This is a positive development for MSP stakeholders given that many believe CMS’ ORM Termination rules are overly restrictive. On its face, it is unclear how this will serve to widen an RRE’s ability to terminate ORM given that the prior rule implicitly permitted an RRE to terminate ORM based upon state and federal law.

For multiple settlements involving the same individual, CMS now provides the following updated guidance in bold:

If there will be multiple TPOCs submitted for the same individual, for the same incident, but reported by different RREs (proportionate or several liability but not joint and several), the records shall reflect each RRE’s unique TPOC amount and not the aggregate TPOC the beneficiary will be receiving. If more than one RRE has assumed responsibility for ongoing medicals, Medicare would be secondary to each such entity.

This is another example of a helpful reminder and clarification rather than a substantive update. Here, CMS essentially restates what it has written elsewhere in the User Guide (Section 6.1.7 – Multiple Defendants) and has stated many times previously: where multiple defendants are released in a global settlement involving a Medicare beneficiary, each defendant is contributing separate amounts, and each defendant is severally liable (e.g., legally  responsible only for their specific portion rather than the entire settlement amount), the defendant shall report their unique TPOC amount.

For Medicare Set-Aside reporting with multiple dates of incident, CMS now provides the following updated guidance in bold:

As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting each RRE must report the total MSA Amount—not just its assigned or proportionate share. System logic exists such that only the first reported MSA amount will be applied for purposes of coordination of benefits.

MSA reporting for multi-defendant settlements has long been a point of confusion for RREs since the inception of MSA reporting on April 4, 2025, and it is even more nebulous when multiple DOIs are involved. CMS’ added language suggests that even in scenarios where there are multiple defendants with several liability, each RRE must report the total MSA amount even if that particular RRE is not contributing to the MSA. It appears that for the sake of simplicity, CMS prefers all MSA values to match and CMS’ system logic will understand that there are not multiple MSAs.

Taken in context with other sections of the NGHP User Guide, it would appear that in a settlement with multiple defendants, multiple DOIs, one MSA, and proportionate or several liability, each defendant would report their own unique TPOC value but all defendants must report the same total MSA value. Hopefully it would not raise a flag with CMS or cause a reporting error if, for example, the defendant’s total reported TPOC is less than the reported MSA amount (e.g., multi-defendant settlement with several liability where Defendant A reports $100,000 MSA value but also reports a $20,000 TPOC because that is the amount that it actually contributed per the terms of the settlement agreement).

April 13th WCMSA Reference Guide Update

CMS noted the following changes to the WCMSA Reference Guide:

·         Additional ZIP codes have been added to the table listing major medical centers (Appendix 7).

·         The CDC Life Table link has been updated (Section 10.3).

With respect to the CDC Life Table, CMS references the following National Vital Statistics Report, dated July 15, 2025, which CMS will use to determine an injured claimant’s life expectancy for purposes of determining the appropriate length of medical care: https://www.cdc.gov/nchs/data/nvsr/nvsr74/nvsr74-06.pdf.  

Final Thoughts

Section 111 Reporting has become more complex, often requiring a detailed view of claim specifics to determine the correct reporting course.  Difficulties with reporting multiple injury cases are still a concern that will hopefully be addressed more fully by CMS in the future to better reflect what is occurring on each specific claim file. What is clear from all the updates and requirements CMS has rolled out over the last several years is that a compliant Section 111 Reporting program requires a group effort.  Working with a partner who helps you identify reporting issues and gaps, provides ongoing education and support; and has the subject matter experience in this complex arena is a key part of that effort. 

If your organization has questions regarding CMS webinar, the NGHP User Guide updates, the WCMSA Reference Guide updates, or would like more information about Sanderson Firm’s Medicare Set-Asides, Section 111 reporting solutions, or conditional payment lien services, please contact us.