CMS Releases Section 111 NGHP User Guide (Version 8.1)

May 7, 2025 / 4 min read

The Centers for Medicare and Medicaid Services (CMS) has released an updated Section 111 NGHP User Guide (Version 8.1, May 5, 2025) regarding Section 111 reporting related to non-group health plans (NGHPs) (liability, no-fault and workers’ compensation).

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As usual, CMS lists the new updates in the beginning of each User Guide chapter in a “Summary” page. In reviewing these pages, CMS indicates that it has made changes to Chapter IV (Technical Information).^[1]The changes relate to the applicability of CMS’s $750 TPOC reporting threshold for “alleged ingestion, implantation, or exposure cases” regarding no-fault and workers’ compensations coverages, with CMS reversing an update it had made to this area last month.

Specifically, in April, CMS, as part of its prior Section 111 NGHP User Guide (Version 8.0, April 7, 2025) made a change to its $750 TPOC reporting threshold for “alleged ingestion, implantation, or exposure cases” regarding no-fault and workers’ compensations coverages. Per this update, CMS stated that “[a] clarification has been added that the reporting threshold does apply to non-trauma no-fault and workers’ compensation cases (Section 6.4).” This change, as more fully discussed in our recent article, represented a departure from prior CMS guidance.

However, this change made in April has proven to be short-lived as CMS, as part of its new Version 8.1 update, has now advised that the change it made last month “was made in error.”^[2]Thus, per CMS’s new Version 8.1 updates, CMS has returned to its previous policy that its $750 TPOC reporting threshold does not apply for “alleged ingestion, implantation, or exposure cases” regarding no-fault and workers’ compensation coverages and that “[a]ny settlement, regardless of amount, should be reported for these types of cases.”^[3]

For those interested in more background and information on these changes, the authors outline the following for review and consideration:

April Version 8.0 updates (now rescinded)

As part of its Section 111 NGHP User Guide (Version 8.0, April 7, 2025) updates, CMS revised its policy regarding its $750 TPOC reporting threshold for “alleged ingestion, implantation, or exposure cases” regarding no-fault and workers’ compensations coverages. In a nutshell, as part of the Version 8.0 updates, CMS removed its prior policy stating that the $750 TPOC reporting threshold did not apply to “alleged ingestion, implantation, or exposure cases” regarding no-fault and workers’ compensations coverages and indicated that its $750 TPOC reporting threshold applied to these cases.^[4]

For perspective, regarding WC cases, CMS’s Version 8.0 update read as follows: “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.”^[5] Similarly, regarding no-fault, CMS’s Version 8.0 update read as read as follows: “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.”^[6]

These Version 8.0 changes, however, were short-lived as CMS has once again revised its $750 TPOC reporting threshold criteria for no-fault and WC cases involving “alleged ingestion, implantation, or exposure cases” outlined below as follows:

May Version 8.1 (CMS returns to prior policy)

As noted above, CMS in its new User Guide Version 8.1 states that the changes made in Version 8.0 (above) were “made in error.”^[7]

Accordingly, as updated in Version 8.1, CMS’s policy regarding its $750 TPOC reporting threshold for “alleged ingestion, implantation, or exposure cases” regarding workers’ compensation and no-fault coverages is as follows:

Regarding WC claims, CMS states, in pertinent part, as follows: “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.” Section 111 NGHP User Guide (Version 8.1, May 5, 2025), Chapter IV, Section 6.4.4.

Regarding No-Fault claims, CMS states, in pertinent part, as follows: “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.” Section 111 NGHP User Guide (Version 8.1, May 5, 2025), Chapter IV, Section 6.4.2.

Thus, when the dust settles, per the new Version 8.1 updates, CMS has reversed its Version 8.0 update, and returned to its prior policy that its $750 TPOC reporting threshold “does not apply” to non-trauma no-fault and non-trauma workers’ compensation reporting “for alleged ingestion, implantation, or exposure cases” and, accordingly, “[a]ny settlement, regardless of amount, should be reported for these types of cases.”^[8]

Questions?

Please do not hesitate to contact the authors if you have any questions or would like to learn more about how Verisk can help you with Section 111 reporting.

[1] Section 111 NGHP User Guide (Version 8.1, May 5, 2025), Summary of Version 8.1 Updates.

[2] Section 111 NGHP User Guide (Version 8.1, May 5, 2025), Summary of Version 8.1 Updates. On this point, CMS states in full: “The following change was made in error with Version 8.0, and is removed with this release: A clarification has been added that the reporting threshold does apply to non-trauma no-fault and workers’ compensation cases (Section 6.4).” Id.

[3] Section 111 NGHP User Guide (Version 8.1, May 5, 2025), Chapter IV, Section 6.4.2 and Section 6.4.4.

[4] CMS’s Section 111 NGHP User Guide (Version 7.9, January 6, 2025), Chapter IV, Sections 6.4.2 and 6.4.4.

[5][ CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter IV, Section 6.4.4.

[6] CMS’s Section 111 NGHP User Guide (Version 8.0, April 7, 2025), Chapter IV, Section 6.4.2.

[7] Section 111 NGHP User Guide (Version 8.1, May 5, 2025), Summary of Version 8.1 Updates.

[8] Section 111 NGHP User Guide (Version 8.1, May 5, 2025), Chapter IV, Section 6.4.2 and Section 6.4.4.

CMS Releases Section 111 NGHP User Guide (Version 8.1) – CMS Corrects an “Error” Regarding its $750 TPOC Reporting Threshold

April Version 8.0 updates (now rescinded)

May Version 8.1 (CMS returns to prior policy)

Questions?