The Centers for Medicare & Medicaid Services (CMS) has released significant updates to its Non-Group Health Plan (NGHP) User Guide, particularly in Chapters 3 and 4, introducing new requirements for Workers’ Compensation Medicare Set-Aside (WCMSA) reporting. These changes, outlined in Chapter III Policies v. 7.8 (December 2024), mark a major shift in how WC settlements must be reported starting on April 4, 2025.What’s Changed?
CMS now mandates that all Workers’ Compensation Total Payment Obligation to Claimants (TPOCs) (settlements, judgments, or awards closing out future medicals) include a WCMSA amount—even if the value is $0. Previously, WCMSA reporting was conditional, required only in cases with formal WCMSAs or allocated future medical expenses. The new requirement applies to every TPOC, ensuring Medicare’s interests are consistently addressed in all settlements.
Key Updates in the User Guide
- Chapter 3 (Policy): Establishes uniform reporting by requiring a WCMSA amount for all TPOCs and referencing the WCMSA Reference Guide for calculation methodologies.
- Chapter 4 (Procedures): Provides detailed instructions, examples, and updated reporting timelines to help stakeholders implement the new requirements.
What This Means for You
Workers’ Compensation insurers, self-insureds, attorneys, and claims administrators must adjust workflows to include WCMSA amounts in all TPOC reports, regardless of whether a formal WCMSA is established. Teams should familiarize themselves with the WCMSA Reference Guide to ensure calculations align with CMS expectations.
How To Remain Compliant
- Review and implement the updated reporting requirements in Chapters 3 and 4.
- Use the WCMSA Reference Guide to calculate accurate amounts, even if $0.
- Train your teams on these changes to avoid delays or penalties.
The updated WCMSA reporting requirements mark a shift toward greater transparency and standardization in Workers’ Compensation settlements. By requiring WCMSA amounts in all TPOCs, CMS is strengthening its oversight of Medicare’s interests. By leveraging the WCMSA Reference Guide and implementing internal process adjustments, organizations can ensure compliance and avoid penalties. For further details, feel free to reach out to the MSP Compliance Team at mspcompliance@examworkscompliance.com.
