CMS Section 111 NGHP User Guide Version 7.5 Released

By Mark Popolizio, J.D., Jeremy Farquhar

April 3, 2024 / 12 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 7.5, April 1, 2024) regarding Section 111 reporting related to non-group health plans (NGHPs) (liability, no-fault and workers’ compensation).

CMS Releases S

As usual, CMS lists the new updates in the beginning of each User Guide chapter in a “Summary” page. Reviewing these pages indicates that updates were made to Chapter III (Policy Guidance), Chapter IV (Technical Information), and Chapter V (Appendices). In general, as outlined below, CMS’s updates relate to CMS’s upcoming TPOC/WCMSA reporting requirements and the agency’s “low dollar” TPOC reporting threshold.

The following provides an overview of the changes made in NGHP User Guide (Version 7.5):

CMS’s upcoming TPOC/WCMSA reporting requirements

By way background, CMS is in the process of implementing its new TPOC/WCMSA reporting requirements. In general, back in November 2023, CMS announced plans to require Section 111 Responsible Reporting Entities (RREs) to report various WCMSA data points as part of its TPOC reporting trigger.

Under this new process, RREs will need to report certain WCMSA data points regarding settlements (TPOCs) involving Medicare beneficiaries which include a WCMSA. This reporting will be required for all WCMSAs involving Medicare beneficiaries, whether or not the WCMSA is submitted to CMS for review/approval, and regardless of whether the WCMSA is included as part of a settlement that does not meet CMS’s voluntary WCMSA review thresholds. For further details, see the authors’ recent article.

CMS held its initial webinar on this new policy in November 2023. CMS then issued an Alert dated February 23, 2024 (February Alert) providing additional information, including the data fields to be reported and new Section 111 error codes. Voluntary testing starts October 7, 2024. CMS’s February Alert notes that the upcoming changes will become effective April 4, 2025. Further, the February Alert indicated that all updated requirements are prospective in nature and the new WCMSA related data will only be required for coverage reports with TPOC dates April 4, 2025, or later. Of note, CMS is holding a second webinar on April 16, 2024 to further discuss this new reporting requirement.

Against this backdrop, CMS has now added information about its forthcoming TPOC/WCMSA reporting process as part of NGHP User Guide (Version 7.5). In general, CMS has essentially incorporated the information it has released to date (as noted above) into the new User Guide. On this point, the authors have not identified any new substantive information or changes as part of CMS’s updates.

With the above stated, the authors note the following in terms the updates made by CMS in the new User Guide regarding its upcoming TPOC/WCMSA reporting process:

Chapter III, Section 6.5.1.1

This section has been updated to reflect the prospective nature of this process. On this point, CMS has added the following language to this section: “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.”^[1]

Chapter IV, Sections 6.1 and 6.4.4

These sections, which relate to the Claim Input File, have also been updated. Specifically, Section 6.1 (similar to the changes made in Chapter III, Section 6.5.1.1) references that the new changes are prospective in nature stating as follows: “For records with a TPOC date on or after April 4, 2025, Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) are to be reported.”^[2]

In addition, Section 6.4.4 was updated to reflect that the WCMSA data points are required to be reported for any WCMSA greater than $0 stating: “For workers’ compensation records with a TPOC date on or after April 4, 2025, and a TPOC amount greater than $0, Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) must be reported.”^[3] Of note, while CMS specifically indicated that changes were also made to Section 6.5 within their Summary update page at the beginning of Chapter IV, the authors’ have been unable to identify any changes having been applied to Section 6.5.^[4]

Chapter V, Appendices A and G (related data fields and error codes)

The noted appendices have also been updated. Specifically, CMS notes the changes as follows in in its Summary update page at the beginning of Chapter V: “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).”^[5]

Furthermore, the following language has been inserted prior to the start of the Claim Input File layout within Appendix A: “Note: Starting April 4, 2025, Field 37, currently reserved for future use, will be repurposed: A new set of fields will be inserted in the beginning of Field 37 and numbered accordingly, and what is currently Field 37 and onward will become Field 44 and onward. Field 44 will contain the remainder of the filler currently in Field 37. The new fields have been added to the current layout below, with an asterisk (*) before the field number. Renumbering of subsequent fields will not take place till the new fields are live.”^[6]

In addition to the above updates to the Claim Input File layout, CMS has also added their new WCMSA related error codes to the Claim Response File Error Code Resolution Table located in Appendix G.^[7] All new WCMSA related error codes begin with an alpha prefix of “CW” and each correlates directly with one of the new WCMSA related fields which have been added to the Claim Input File layout located in Appendix A.

Low Dollar Threshold (2024)

As part of the new User Guide, CMS also includes information regarding its low dollar threshold for 2024, which remains at $750 for certain claims as more fully explained by CMS below. In this regard, CMS references that information regarding its low dollar threshold is contained in Chapter III, Section 6.4 and Chapter IV Section 6.4.

In reviewing the above sections, CMS states its low dollar threshold as follows in User Guide (Version 7.5):

Liability Insurance (including Self-Insurance) TPOCs

As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. This threshold does not apply to non-trauma liability reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.^[8]

No-Fault Insurance TPOCs

As of January 1, 2024, CMS will maintain the $750 threshold for no-fault insurance, where the no-fault insurer does not otherwise have ongoing responsibility for medicals. This threshold does not apply to non-trauma no-fault reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.^[9]

Workers’ Compensation TPOCs

As of January 1, 2024, CMS will maintain the $750 threshold for workers’ compensation settlements, where the workers’ compensation entity does not otherwise have ongoing responsibility for medicals. This threshold does not apply to non-trauma workers’ compensation reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.^[10]

In reviewing the language above, careful attention should be paid to which cases CMS’s “low dollar” threshold applies, and to which cases the low dollar threshold does not apply. Specifically, as will be noted, in each scenario above CMS excludes “non-trauma” claims (alleged ingestion, implantation, or exposure cases) from its low dollar threshold. In this regard, the above verbiage can be viewed as clarifying CMS’s recent Alert (and prior Alerts), and verbiage contained in prior editions of its User Guide, which seemed to indicate, textually, that the low dollar threshold did not apply to non-trauma claims specifically in relation to liability TPOCs alone. However, in reviewing the above passages, CMS’s updates reflect that its low dollar threshold does not apply regarding non-trauma claims for liability TPOCs, as well as workers’ compensation and no-fault TPOCs as discussed more fully in the endnote to this sentence.^[11]

Questions?

Please do not hesitate to contact the authors if you have any questions, or to learn how Verisk can help you address Section 111 reporting issues.

[1] CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter III, Section 6.5.1.1.

[2] CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter IV, Section 6.1.

[3]CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter IV, Section 6.4.4.

[4] CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter IV, Section 1.

[5]CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Summary of Version Updates page (p.1-1).

[6] CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter V, Appendix A.

[7] CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter V, Appendix G.

[8]CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapters III and IV, Section 6.4.3.

[9] CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter III and IV, Section 6.4.2.

[10] CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter III and IV, Section 6.4.4.

[11] As an example, CMS stated the following in its recent Alert dated February 14, 2024 (2024 Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards or Other Payments):

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.

In reviewing this passage from CMS’s February 14, 2024 Alert (which is verbiage CMS has used in several prior Alerts over the years), the exclusion of non-trauma claims, from a textual stand point, could be interpreted to apply only to liability (including self-insurance claims) TPOCs – to wit, “Please note that the liability insurance (including self-insurance) threshold does not apply to settlements for alleged ingestion, implantation, or exposure cases.” CMS’s February 14, 2024 (authors’ emphasis). However, CMS in the User Guide sections outlined above in User Guide (Version 7.5) reflects that the exclusion of “non-trauma” claims from its low dollar threshold also applies to no-fault and workers’ compensation TPOCs. See, CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapters III and IV, Section 6.4.3.

Along these lines, similar verbiage changes are also noted to actual User Guide Section 6.4.2 (no-fault TPOCs) and Section 6.4.4 (workers’ compensation TPOCs) outlined as follows:

Specifically, for example, in NGHP User Guide (Version 7.4, January 22, 2024), this section included the following verbiage in Section 6.4.2 regarding no-fault TPOCs: “This threshold does not apply to non-trauma liability reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.”” NGHP User Guide (Version 7.4, January 22, 2024), Section 6.4.2 (authors’ emphasis). As will be noted, CMS referenced “non-trauma liability” in this section, despite the fact this section relates to no-fault claims. CMS, as part of the User Guide (Version 7.5) updates, has now amended this language by removing “liability” and replacing that, instead, with “no-fault.” Thus, this verbiage in Section 6.4.2 now reads, as noted above, as follows: “This threshold does not apply to non-trauma no-fault reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.” CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter III and IV, Section 6.4.2. (authors’ emphasis).

Likewise, similar changes have been made to Section 6.4.4 regarding workers’ compensation TPOCs. Specifically, for example, in NGHP User Guide (Version 7.4 January 22, 2024), this section included the following verbiage in Section 6.4.4 regarding workers’ compensation TPOCs: “This threshold does not apply to non-trauma liability reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.” NGHP User Guide (Version 7.4, January 22, 2024), Section 6.4.4 (authors’ emphasis). Again, as will be noted, CMS referenced “non-trauma liability” in this section, despite the fact this section relates to workers’ compensation claims. CMS, as part of the User Guide (Version 7.5) updates, has now amended this language by removing “liability” and replacing that, instead, with “workers’ compensation.” Thus, this verbiage in Section 6.4.2 now reads, as noted above, as follows: “This threshold does not apply to non-trauma workers’ compensation reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.” CMS’s Section 111 NGHP User Guide (Version 7.5, April 1, 2024), Chapter III and IV, Section 6.4.4.

From the authors’ experience, CMS’s inclusion of “non-trauma liability reporting” in prior versions of Section 6.4.2 and 6.4.4 dealing with no-fault and workers’ compensation TPOCs, respectively, caused confusion for many RREs as it was uncertain whether CMS intended to simply restrict non-trauma claims for only liability TPOCs from its “low dollar threshold,” or whether this exclusion also applied to non-trauma no-fault and workers compensation TPOCs. Based on the new verbiage updates made in User Guide (Version 7.5) as outlined above in the body of this article and this endnote, it appears that CMS has clarified that its low dollar reporting threshold does not apply to non-trauma claims (alleged ingestion, implantation, or exposure cases) for liability TPOCs, as well as workers’ compensation and no-fault TPOCs.

CMS releases Section 111 NGHP User Guide (Version 7.5)