The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 7.9, January 6, 2025) regarding Section 111 reporting related to non-group health plans (NGHPs) (liability, no-fault and workers’ compensation).
As usual, CMS lists the new updates in the beginning of each User Guide chapter in a “Summary” page. Reviewing these pages indicates that updates were made to Chapter III (Policy Guidance) and Chapter IV (Technical Information). In general, CMS has updated the User Guide to note, per its recent Alert, that it is retaining its $750 low dollar reporting and recovery thresholds for certain claims in 2025.
Summary
As part of its Version 7.9 release, CMS notes that updates regarding the $750 low dollar threshold were made to Sections 6.4 in Chapters III and IV of the User Guide.
In terms of the low dollar threshold’s application (and non-application), these sections, in pertinent part, read as follows:
No-Fault TPOCs (Section 6.4.2)
As of January 1, 2025, CMS will maintain the $750 threshold for no-fault insurance, where the no-fault insurer does not otherwise have ongoing responsibility for medicals. This threshold does not apply to non-trauma no-fault reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.[1]
Liability Insurance (including Self-Insurance) TPOCs (Section 6.4.3)
As of January 1, 2025, the threshold for physical trauma-based liability insurance settlements will remain at $750. This threshold does not apply to non-trauma liability reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.[2]
Workers’ Compensation TPOCs (Section 6.4.4)
As of January 1, 2025, CMS will maintain the $750 threshold for workers’ compensation settlements, where the workers’ compensation entity does not otherwise have ongoing responsibility for medicals. This threshold does not apply to non-trauma workers’ compensation reporting for alleged ingestion, implantation, or exposure cases. Any settlement, regardless of amount, should be reported for these types of cases.[3]
Authors’ Comments
In each of the above scenarios, careful attention should be paid to which cases CMS’s “low dollar” threshold applies, and to which cases the threshold does not apply. For example, in each of the three TPOC scenarios above, CMS states that its low dollar threshold does not apply in situations involving “alleged ingestion, implantation, or exposure cases.”[4] On another note, regarding No-Fault and Workers’ Compensation TPOCs, CMS’s language above notes that the threshold only applies to scenarios where the insurer “does not otherwise have on-going responsibility for medicals.” These distinctions should be noted in determining the application of CMS’s $750 low dollar threshold.[5]
Questions?
Please contact us with any questions regarding the above. Visit our Section 111 reporting page to learn more about how Verisk can help you address your needs.
[1] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapters III and IV, Section 6.4.2.
[2] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapters III and IV, Section 6.4.3.
[3] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapters III and IV, Section 6.4.4.
[4] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapters III and IV, Sections 6.4.2, 6.4.3, and 6.4.4).
[5] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapters III and IV, Sections 6.4.2 and 6.4.4).