On Monday, October 5, 2026, CMS released Version 8.6 of the MMSEA Section 111 Non-Group Health Plan (NGHP) User Guide. The latest update offers significant details on several issues that continue to generate questions from industry stakeholders. Among the highlights are a reiteration of WCMSA reporting requirements, clarification regarding when wrongful death claims must be reported, and written policy guidance addressing how RREs should correct or remove erroneous TPOC reporting.
Key Highlights:
Chapter III – Policies – Section 6.5.1.1
The recent policy change mandating the reporting of WCMSAs was at the forefront last year, creating both technical and operational challenges for claims payers. This User Guide reinforces the requirement by expressly stating:
“For workers’ compensation records submitted on a production file with TPOC date on or after April 4, 2025, Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) must be reported.”
While the requirement is not new, the inclusion of this language in the User Guide provides an important reminder that WCMSA reporting is firmly embedded within the Section 111 reporting framework.
Chapter III – Policies – Section 6.5.1.4
This section thoroughly clarifies, in no uncertain terms, when to report wrongful death claims. ECS previously explained CMS’ evolving clarifications surrounding this topic in a recent blog. At that time, CMS’ focus appeared to be on conditional payments in wrongful death settlements. The prior guidance stated the following:
“In order for the wrongful death theory of liability to preclude Medicare from recovering from a settlement, judgment, award, or other payment, complete documentation must be provided that shows what was claimed and released or had the effect of being released. Additionally, a citation to the appropriate state statute or case law that precludes recovery from a wrongful death settlement should be included with any such dispute or appeal.”
As a result, whether a settlement releases or has the effect of releasing medicals would determine whether the settlement should be reported. In other words, do not report the wrongful death claim unless medicals are being released.
However, the new User Guide would indicate that unless it is clear there is no permittable recovery of medicals, RREs should report wrongful death settlements. Version 8.6 reads:
“Many states allow for the recovery of medical expenses from the proceeds of a wrongful death settlement, judgment, or award. Further, oftentimes, a complaint alleging the wrongful death theory of liability, and the settlement documents related to an alleged wrongful death cause of action, are written in such a way that medicals are claimed and released or have the effect of being released, whether or not the parties intended that result. As such, RREs are required to report any wrongful death settlement unless the RRE is able to definitively determine that all relevant documents, state law, and common law, do not permit for the recovery of medical expenses from the payment being made and that medicals were not released or had the effect of being released.”
This update serves as a warning for counsel. The key takeaway being – don’t get cute with the language. While many rest on the tried-and-true boilerplate release, settlement agreements for these types of claims call for express language so there is no room for interpretation. If not handled correctly, even if the parties did not intend for the language to have the effect of releasing medicals, RREs may be required to report the wrongful death settlement. Here, a meeting of the minds may not save you, but definitive language will.
Chapter IV – Technical Information – Section 6.4.5
In a move many have been awaiting, CMS has now formalized the process of correcting or removing previously submitted or erroneous TPOC reporting. On the heels of the WCMSA reporting requirements, we witnessed a small number of claims impacted when a TPOC was reported before completion of the voluntary WCMSA review process. In those instances, the WCRC essentially shutdown review, and changed the file to a Completed status, thus taking no further action on the voluntary WCMSA submission. Whether this recent update will provide a path forward for those impacted claims remains to be seen.
Historically, when a TPOC needed to be reported or changed, a simple Update Record was sent to CMS. Effective April 2027, however, CMS will require a combination of Delete and Add records to be submitted if the TPOC (or multiple TPOCs) needs to be removed entirely. The Delete record will remove the previously submitted claim information, while the Add record will allow the claim to be resubmitted to CMS without the TPOC data.
More specifically, to remove an erroneous TPOC, the system will recognize the removal of TPOC and WCMSA data when the existing TPOC or WCMSA data have non-zero values and are being updated to zero values for workers’ compensation and no-fault claims where ORM exists. Of note, the guidance regarding when to send a Delete record has not been modified. When “key fields” change, a Delete record must still be submitted. CMS continues to identify the following as key fields: CMS DOI; Plan Insurance Type; Policy Number; ORM Indicator.
This requirement to submit a Delete record for removing the TPOC data is a significant shift in technical guidance, as it requires not only monitoring fields for changed values, but also identifying what those values are changing to. And since this requires programming changes, CMS is affording the customary 6-month advanced notice. RREs that report through a vendor such as ECS should have no issue implementing this change. However, for RREs that report directly to CMS, this modification may be more significant.
In light of CMS’ evolving policy changes, RREs should continue to keep their finger on the pulse, paying considerable attention to technical reporting updates that influence compliance obligations. ECS is available to help assess the effect of these changes on your reporting program. Should you have any questions please contact ECS MIR Service Support or the ECS Compliance Team at mspcompliance@examworkscompliance.com.