This week, CMS released Version 8.5 of the MMSEA Section 111 Non-Group Health Plan (NGHP) User Guide and Version 4.6 of the Workers Compensation Medicare Set Aside Reference Guide. Consistent with agency practice, these updates center primarily on refining operational guidance as opposed to presenting sweeping substantive changes. Although these updates do not fundamentally alter existing compliance obligations, they do provide useful insight into CMS’ evolving expectations and processes. Here are the updates that stood out.
Rather than introducing new requirements, this latest version focuses on existing policies surrounding ORM termination, TPOC reporting, and reporting scenarios involving multiple dates of injury (DOIs) or multiple Responsible Reporting Entities (RREs).
As you may recall, CMS modified its guidance in April to significantly expand ORM termination opportunities, which we blogged about here. Needless to say, the industry welcomed CMS’ willingness to recognize circumstances where contract, state law, or federal law would permit an RRE to terminate responsibility for medical benefits, absent another basis specifically permitted by CMS. Just one month later, CMS issued a “Request for Feedback” regarding the ORM termination policy, soliciting input from the stakeholder community on potential revisions. Given CMS’ direct outreach on the issue, many anticipated that additional changes would be incorporated into this release. However, this version contains no further modifications to CMS’ ORM termination framework.
With respect to WCMSA reporting requirements, CMS specifically addressed the “hard error” scenario when reporting an incorrect Case Control Number (CCN). WCMSAs that are submitted to CMS for voluntary review and approval are assigned a CCN. Within the User Guide, Chapter V now explicitly notes that if a CCN is provided and does not correspond to or match an existing WCMSA case, the entire record will be rejected. Given the vast room for error, compounded with the fact that a CCN is not a required reporting field, the risk of providing this information far outweighs the benefit. As such, our recommendation has been to avoid this pitfall altogether unless you are confident that the CCN is accurate.
Turning to the WCMSA Reference Guide, CMS made several noteworthy updates to both Approval Letter language and the newly introduced Notice of Settlement Letter associated with mandatory WCMSA reporting. Among other changes, approval letters now provide additional clarification regarding the administration of structured WCMSAs when annual deposits are either underutilized or exhausted during a given period.
CMS also added language to the Notice of Settlement Letter to reinforce beneficiary responsibility with respect to Medicare Advantage (Part C) and Prescription Drug (Part D) plans. Specifically, beneficiaries are encouraged to provide these plans with information concerning the exact treatment and medications expected to be paid from the WCMSA funds. In line with CMS’ objective, this guidance works to ensure proper coordination of benefits post settlement.
While the overarching theme of these updates is clarification rather than expansion, RREs should continue to review CMS updates, paying particular attention to technical reporting requirements that may affect ongoing compliance obligations. As the industry has seen before, even seemingly minor revisions can impact claim handling workflows, reporting logic, and compliance exposure, particularly in the era of increased focus on Section 111 Civil Money Penalty (CMP) enforcement.
ExamWorks Compliance Solutions is available to help assess the effect of these and other changes to your reporting program. Should you have any questions please contact your local ECS regional compliance consultant, ECS MIR Service Support, or the ECS Compliance Team at mspcompliance@examworkscompliance.com.