Medicare Advocacy and Recovery Coalition

MEDICARE SECTION 111 REPORTING POLICIES

MEDICARE SECTION 111 REPORTING POLICIES

The Centers for Medicare & Medicaid (CMS) has historically adopted Section 111 reporting policies that fit the Agency’s existing systems.  Because Congress, without stakeholder input (MARC did not exist at the time) permitted CMS to implement the Section 111 reporting regime by “program manual,” CMS does not undertake notice and comment rulemaking pursuant to the Administrative Procedures Act but instead has issued, and frequently updates,  the Section 111 Non-Group Health Plan (NGHP) User Guide.  Over the years, as MARC has worked with CMS to educate the Agency about how insurers and self-insureds settle cases and maintain their claims data, the Agency has adapted the User Guide to ensure it is practical for reporting entities, and that commercial claims systems can interface with the CMS reporting system. 

In recent years, starting in 2025, however, CMS has adopted a series of reporting requirements that do not reflect how cases are resolved, or how claims systems and data are maintained.  These changes include modification to the manner in which settlements, judgments and awards are reported for individuals with multiple claims for multiple dates or injury, which CMS now requires all be reported using the first date of injury.  Similarly, CMS also now requires Workers’ Compensation Medicare Set-Aside (WCMSA) arrangements to be reported by the settling party, rather than the beneficiary for whose benefit the WCMSA has been created.  These changes in reporting have significant implications for beneficiaries, reporting entities, and even CMS. 

MARC is dedicated to improving the Section 111 reporting process, and to ensuring that CMS reporting requirements can be implemented by stakeholders, and do not improperly burden beneficiaries and reporting entities.  MARC calls on CMS to fully understand how the claims systems works, how claims are settled, and to appreciate the impact of new CMS policies on both reporting entities and beneficiaries, when amending the User Guide. 

MARC REPORTING POLICY:  CMS SHOULD SIMPLIFY AND UPDATE SECTION 111 REPORTING POLICIES

The MARC Coalition calls upon CMS to update and simplify its Section 111 Reporting Policies.  In specific, MARC is asking CMS to revoke certain recent (2025) changes to the Section 111 NGHP User Guide which: (1) require reporting of all settlements to a beneficiary with multiple claims on multiple dates of injury as if they all occurred on the first date of injury; and (2) requiring reporting of Workers Compensation Medicare Set Asides (WCMSAs). 

CMS Multi-Claims Policy is Harming Beneficiaries and Reporting Entities

In November 2025, CMS updated the Section 111 User Guide to Version 8.2, fundamentally changing the manner in which cases with multiple events or multiple responsible parties are to be reported and asking for information to be reported in a manner that would be impossible to use for proper benefits coordination with the beneficiary following settlement.  The reporting change cannot be implemented by many reporting entities and would require reporting inaccurate information – all of which CMS should have known.  But as important, beneficiaries involved in the MSP program are now at risk that CMS will over-collect from them for conditional payments owed in liability cases given that CMS can no longer tell when a claim first arose, and will seek to collect from the first date of incident for all treatments, including those that only occurred years after the first date of incident.  

In brief, current Section 111 reporting framework requires reporting entities to report a separate Total Payment Obligation to the Claimant (TPOC) record for each distinct claim or Date of Incident (DOI). Each report reflects the individual claim’s facts — including the injury or body part, ICD codes, settlement amount, and date of injury— ensuring that CMS’s data accurately aligns with the claim record, jurisdictional filings, and payment details.  In the November 2025 update, however, CMS added new guidance directing that, when a single settlement, judgment, award, or other payment resolves multiple incidents (different injury dates), the reporting entity should report a record for the earliest date of incident which includes all ICD codes for injuries being settled for all dates of incident back to the first date of injury.  For example, if in 2020 the beneficiary sprained their wrist, in 2022 they broke their back, and in 2024 the claims were resolved in a settlement, the back injury would be reported as happening in 2020 when it only occurred in 2022.   

The proposed change does not align with how industry retains claims files, is not implementable by industry due to the structure and design of reporting systems, and would result in the reporting of inaccurate information to CMS.  While the Agency claims “it will figure it out on the back end,” that is not a solution to what already is an overly complex and broad system.  Moreover, while insurers and self-insured can negotiate with CMS and eliminate inappropriate CMS conditional payment demands, beneficiaries rarely have the experience or skill to do so are at risk of being charged for conditional payments that they do not actually owe.   

MARC has previously asked CMS to propose these kinds of changes in a draft so that we and others could assist in identifying issues in the proposed changes, but CMS has refused to do so.  Unfortunately, CMS has missed the mark with this change; the systems that reporting entities rely upon cannot be changed to implement the new policy, reporting entities should not be asked to report false information, and beneficiaries will suffer.  MARC calls on CMS to withdraw the policy.  

WCMSA Reporting is Harming the MSP Program

From the outset of CMS’s announcement during the Biden Administration that it was considering WCMSA reporting within Section 111, MARC raised with CMS three concerns, which unfortunately have come to fruition.  

Delaying Settlements:  WCMSA reporting has resulted in delaying workers’ compensation settlements.  More specifically, although unannounced by CMS, the Agency has chosen to terminate review of proposed WCMSAs based on WCMSA Section 111 reports that either have a difference in information from that before the WCRC or even when a TPOC (total payment of claim) is reported.  As a result of the WCMSA process, many parties  have become unable to complete workers’ compensation settlements, harming beneficiaries that would have been able to resolve their claims but for the WCMSA reporting process and ironically leaving Medicare as the primary payer on the claim that now cannot settle. 

Transparency:  CMS has not been clear as to what it wants and does not want to be reported, and how the reported information will be used.  CMS has never communicated to stakeholders that WCRC WCMSA review would be terminated based upon issues with Section 111 reporting.  As a result, parties with pending WCMSAs under review before the WCRC do not know whether review is being suspended or prior approvals revoked.  Further, CMS has failed to address how WCMSA reporting should occur in complex multiparty/multi-body part or multi-date of injury/same claimant settlements.  

Purpose.  CMS has not explained why it is collecting WCMSA information from reporting entities (as opposed to the beneficiaries for whom the WCMSA is created and who actually operate the WCMSA) and to what purpose it will put the data.  Unfortunately, other than a hazy “to coordinate benefits” response, CMS has never explained why it is collecting this information, and to what purpose the data will be used.  It is particularly unclear how the WCMSA reporting will be used to effectively or accurately coordinate benefits following complex multi-party/multi-body part settlements.  While some settlements are between a claimant and one carrier/employer, there are many that are global resolutions of claims by the beneficiary against multiple employers/carriers. For these settlements, the defendants are not jointly and severally liable. The settling claims can involve different body parts with some fully denied and have different dates of injury, coverage periods, or employment periods.

For that reason, MARC calls on CMS to make the following changes to the WCMSA reporting system:

Reduce WCMSA “reporting” to one question – is a WCMSA part of the settlement or not?  This will eliminate the need to address the numerous complex situations that are implicated in the workers’ compensation process.   Given that the WCMSA is created for the benefit of, and operated by, the beneficiary, there is no reason that reporting entities should be involved in reporting details beyond the overall TPOC in the first instance.  

Address Multi-party and Global settlements/Multi-body part settlements.  If CMS does not reduce the WCMSA reporting process to the one question proposed above, it must address in detail multi-party settlements, multi-body part settlements, global settlements, and MSAs funded in whole or in part by third-party settlements.  We have repeatedly advised CMS that it is not unusual in workers’ compensation settlements that multiple parties will be involved in a settlement, that parties reach global settlements, and that multiple body parts can be addressed in one or more settlements.  Yet, the WCMSA reporting rules do not address these situations, and it is unclear if it is even possible to adequately do so.  CMS has also not acknowledged that there is no joint and several liability in such situations.  We ask that CMS clearly address this issue as well.

CMS already collects an extensive amount of data from beneficiaries or their professional administrators about the WCMSA and how it is being used.  This data could readily be linked to any reporting entity Section 111 report if CMS chose to do so.  There is no reason that reporting entities should be obligated to report any data about a WCMSA.  MARC calls on CMS to withdraw the reporting requirement.