CMS Updates NGHP User Guide & WCMSA Reference Guide

On April 7, 2025, the Centers for Medicare & Medicaid Services (CMS) issued:

• Version 8.0 of the NGHP User Guide
• Version 4.3 of the Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide

What is new in the NGHP User Guide?

• Chapters II – V: Updates to include field numbers for the new WCMSA reporting requirements, which became effective 4/4/2025.
• Chapter IV: Clarification that the reporting threshold does not apply to non-trauma no-fault and workers’ compensation cases.
• Chapter IV: The Event Table (Section 6.6.4) was updated to include three new scenarios involving MSA corrections.
• Chapter V: As of 10/6/2025, the recovery agent TIN field is required if the agent’s name is submitted.
• Chapter V: Zip+4 section guidance was updated

Most of the above updates were updates involving clarification and field numbers for the new WCMSA reporting requirements that are now in place. Of the other updates, the notable change includes the TIN field being required for the recovery agent starting 10/6/2025 if the recovery agent’s name is submitted.

What is new in the WCMSA Reference Guide?

CMS included a sample letter for Notice of Settlement Received letter which is used in conjunction with the new WCMSA reporting requirement. This letter essentially lets the claimant know that CMS received reporting indicating the workers’ compensation settlement had a MSA reported and that there is an expectation that the WCMSA portion be used to pay for medical and pharmacy care related to the workers’ compensation injury. CMS will also include an enclosure regarding annual attestation submission as well as a link to the Self-Administration Toolkit.

CMS also updated the WCMSA Reference Guide with previously known items such as:

• The removal of the one-year waiting period for the amended review.
• For WCMSA submissions involving a change of submitter, CMS requires a written release from services by the current submitter and a signed Consent to Release from the new submitter. The big change here is CMS previously required a written release from the original submitter, which is no longer the case.
• Clarification that a change of submitter is not sufficient grounds to require an amended review.

How can ExamWorks help me with navigating Section 111 reporting or Medicare Set-Asides?

ECS and our expert team is available to assist you with your Section 111 and Medicare Set-Aside needs and help make sure your settlements adequately consider Medicare’s interest. We will continue to keep readers apprised of further agency developments from CMS as we monitor this and all areas of MSP compliance closely. If you have any questions, please do not hesitate to reach our compliance team at mspcompliance@examworkscompliance.com.