CMS Solicits Responses Regarding ORM Termination Criteria
On May 26, 2026, the Division of Medicare Secondary Payer Program Operations (DMPO) issued a solicitation requesting feedback on Section 111 Ongoing Responsibility for Medical (ORM) termination. Specifically, DMPO seeks input on whether the current parameters for ORM termination are “appropriate, reasonable, and sufficient.”
Feedback, concerns, ideas, or questions must be submitted no later than June 9, 2026. All submissions should be sent to the new DMPO-managed mailbox for Coordination of Benefits and Recovery (COB&R) inquiries at COBR@cms.hhs.gov.
The Centers for Medicare & Medicaid Services (CMS) released Version 8.4 of the MMSEA Section 111 NGHP User Guide in April 2026. Chapter III, Section 6.3.2 of the Policy User Guide was updated to include the following language (emphasis added) within the criteria for ORM termination:
Where the insurer’s responsibility for ORM has been terminated pursuant to the terms of the applicable insurance contract, such as upon exhaustion of maximum coverage benefits, or for any other reason 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, constitutes a valid ORM termination reason, provided that such refusal is permitted by applicable state or federal law and the terms of the insurance contract.
This additional language appears to reflect an effort by CMS to broaden the basis for ORM termination. However, CMS did not provide specific examples and instead relied generally on state and federal law as the governing framework. Accordingly, Responsible Reporting Entities (RREs) should use applicable law as a guiding principle when evaluating whether ORM termination is appropriate.
For example, where an Independent Medical Evaluation (IME) determines that a claimant has fully recovered from a work-related injury and no further medical treatment is required—if, under applicable state law, the RRE may cease payment for medical care based on the IME findings, and the RRE provides proper notice to the claimant and discontinues payment—ORM termination may be appropriate. Additional considerations in this analysis should include whether a formal denial is filed within the jurisdiction as well as the content of the applicable state statute of limitations or lack thereof.
Each case must be evaluated individually to determine whether the totality of the circumstances supports ORM termination. The basis for termination should be clearly documented in the RRE’s claim system. The mere passage of time, without more, is insufficient to justify termination, and administrative closures alone do not constitute a valid basis. Equally important, RREs should continue to monitor such claims in the event that ORM Termination is no longer appropriate and updates are required.
Returning to the example above, if a Workers’ Compensation Judge subsequently issues a decision rejecting the IME physician’s findings, the RRE would be required to update its reporting to reflect ORM as ‘Y.’ Failure to do so could result in additional compliance and reporting issues.
Lastly, adequate analysis and supporting documentation will be key if an ORM termination is contemplated in the context of a conditional payment lien. Often these analyses occur when a conditional payment is at issue and in these circumstances Medicare’s contractor will be reviewing the sufficiency of the ORM termination reasoning and supporting documentation. Inadequate documentation or inaccurate ORM terminations could result in unexpected conditional payment exposure.
Given this recent request for industry feedback, it appears CMS is continuing to refine the ORM termination criteria, and further updates may follow based on stakeholder input. Sanderson Firm will continue to monitor developments and provide guidance as additional information becomes available.
If you have any questions regarding the above, or about Section 111 reporting more generally, please do not hesitate to contact us.