CMS Confirms Upcoming Required Reporting of Workers’ Compensation Medicare Set-Asides

Written by: Brendon De Souza, Esq.

Today, the Centers for Medicare & Medicaid Services (CMS) published a technical alert confirming that Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) will be required to report Workers’ Compensation Medicare Set-Aside (WCMSA) information via Section 111 Total Payment Obligation to the Claimant (TPOC) reporting for settlements involving Medicare beneficiaries beginning April 4, 2025.

As noted in a prior Sanderson Firm blog article, CMS previously alluded to “potential” WCMSA reporting in 2025. Today, the Medicare Secondary Payer industry has received definitive confirmation of this upcoming policy requirement.

We would like to remind our readers that WCMSA reporting will only apply to workers’ compensation settlements involving Medicare beneficiaries, and it will also encompass settlements where a WCMSA was not submitted to CMS for review. Settlements involving non-Medicare beneficiary “reasonable expectation” claimants remain outside the scope of WCMSA reporting.

The technical alert also confirms that WCMSA reporting will be prospective; that is, for TPOCs occurring before April 4, 2025, WCMSA reporting is not required. CMS will add new data fields to the Section 111 Claim Input File to capture the desired WCMSA information (e.g., WCMSA Amount, MSA Period, etc.), and RREs will be able to begin testing on October 7, 2024. This provides approximately six (6) months of testing prior to the April 4, 2025 implementation date.

Sanderson Firm Commentary:

For the first time, CMS has expanded Section 111 reporting to capture Medicare-Set Aside information — the significance of which cannot be overstated. It remains to be seen how exactly CMS will use the data gathered. Will CMS share the WCMSA information with private Medicare plans to allow such plans to deny treatment if the private Medicare plan deems the WCMSA insufficient? If so, how much WCMSA information will CMS share with the private Medicare plans? Will this reporting requirement eventually be expanded to liability claims, thus requiring the reporting of Liability Medicare Set-Asides?

One point remains clear for now: CMS has not indicated that the WCMSA reporting requirement seeks to invalidate workers’ compensation non-submit, evidence-based Medicare Set-Asides. Of course, if CMS were to ever challenge a workers’ compensation non-submit, evidenced-based Medicare Set-Aside, CMS would need to be prepared to defend a potential lawsuit brought by the affected Medicare beneficiary for improper suspension or termination of Medicare benefits, which would stand to create unique case law precedent for evidenced-based Medicare Set-Asides.

Due to the policy significance, we strongly encourage RREs to take advantage of the testing period. If you or your organization has questions about this technical alert or would like to learn more about how Sanderson Firm’s Section 111 reporting solution will benefit your organization, please contact us.