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CMS Issues NGHP User Guide Version 7.8

December 13, 2024
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User Guide spelled out in wooden blocks

by B. Smith

The Centers for Medicare & Medicaid Services (CMS) has issued a new Non-Group Health Plan (NGHP) User Guide, Version 7.8. CMS added a new language in Chapter 6, section 6.4.4.4 of Chapter III: Policy Guidance, and Chapter 6, 6.4.4.1 of Chapter IV: Technical Information regarding the new Workers’ Compensation Medicare Set-Aside (WCMSA) reporting obligation which will begin on April 4, 2025.

As noted in our prior blogs addressing this new requirement, as part of the reporting of Total Payment Obligation to Claimant (TPOC), Responsible Reporting Entities (RREs) who settle the medical portion of a workers’ compensation claim (and meet the reporting thresholds) will need to include the amount of any WCMSA used as part of settlement. The specific fields that will be added to TPOC reporting include:

      • WCMSA amount
      • WCMSA period (the amount of time in years the MSA is expected to cover)
      • Whether the WCMSA is going to be paid in a lump sum or structured
      • If structured, the initial deposit amount (seed money) and the annual deposit amount
      • CMS case control number (only needed if the WCMSA was submitted to CMS for approval)
      • The EIN of the professional administrator (not a required field)

CMS notes that all future medical expenses related to a workers’ compensation injury that are claimed, or released as part of settlement, must be included in the WCMSA and the amount of the WCMSA reported, which may be $0 in certain circumstances. CMS again confirms that the submission of WCMSAs is voluntary and states that regardless of the how the amount was determined, the WCMSA must be appropriately exhausted before Medicare will resume payment for injury-related care.

Currently, CMS has opened testing for RREs to help with the implementation of this process. Beginning April 4, 2025, CMS will require Workers’ Compensation RREs to provide this information, regardless of whether the settlement is less than the settlement amount, as long as reporting thresholds are met.

In the wake of these new obligations, what can RREs do now to help ensure compliance?  Below are some recommendations:

      • Confirm that you have the capability within your claim system to include these new reporting fields and that any enhancements to the system will be completed prior to the April 4, 2025 deadline.
      • If you have a reporting agent, make sure they will be able to process this information and report it to CMS on your behalf.
      • Train staff who are imputing this information on what needs to be reported and how to do so.
      • Review your current WCMSA process to determine if you need to update or change your current program.
      • Work with a Medicare compliance partner and reporting partner who can help you identify any gaps in your program and provide solutions to resolve these issues.

If you have any questions regarding updates to the NGHP User Guide v7.8 or would like to learn more about our MSA and Section 111 Reporting services, please contact our Settlement Consulting team at [email protected].