CMS to Apply New Life Tables to WCMSAs as of 4/1/2017

The Centers for Disease Control and Prevention (CDC) recently released United States Life Tables, 2012 reflecting population estimates for 2012 of life populations. Beginning April 1, 2017, the Centers for Medicare and Medicaid Services (CMS) will be utilizing Table 1: Life table for the total population: United States, 2012 for Workers’ Compensation Medicare Set-Aside Agreements (WCMSAs) in regards to life expectancy.

The increases in life expectancy are minor. However, we suggest any previously prepared MSAs be reviewed prior to submission to CMS to verify if there is a change in life expectancy. At Optum, our knowledgeable staff can re-evaluate your MSA, if needed, to verify if there is any impact due to this change.

For questions, please contact our Settlement Solutions Division at 888-672-7674 or

CMS Release

New Life Tables

Social Security Number Removal Initiative

Social Security Numbers (SSN) have been used as the beneficiary identifier for administering the Medicare program since its inception. The Centers for Medicare & Medicaid (CMS) recently introduced the Social Security Number Removal Initiative (SSNRI) to remove the SSN from Medicare Cards. The primary goal of removing the SSN-based Health Insurance Claim Number (HICN) and replacing it with a new Medicare Beneficiary Identifier (MBI) is to decrease Medicare identity theft.

Optum has begun planning for this change, but what does this mean to you? There will be no file format changes to any input or response files used as part of the Medicare Secondary Payer (MSP) data exchange process. Starting in July 2017, reference to the term HICN will be replaced by “MedicareID.” The Medicare ID will universally apply to all MSP processes and will be reflected in all documentation on the Coordination of Benefits & Recovery (COB&R) web site.

CMS has stated that the MBI will have the following characteristics:

  • The same number of characters as the current HICN (11), but it will be visibly distinguishable from the HICN
  • Contain uppercase alphabetic and numeric characters throughout the 11 digit identifier
  • Occupy the same field as the HICN on transactions
  • Be unique to each beneficiary (e.g. husband and wife will have their own MBI)
  • Be easy to read and limit the possibility of letters being interpreted as numbers (e.g. Alphabetic characters are upper case only and will exclude S, L, O, I, B and Z)
  • Not contain any embedded intelligence or special characters
  • Not contain inappropriate combinations of numbers or strings that may be offensive

CMS will complete its system and process updates to be ready to accept and return the MBI on April 1, 2018. Stakeholders may submit or exchange the MBI or HICN during the transition period which runs from April 1, 2018 through December 31, 2019.

After January 1, 2020, Section 111 MMSEA Responsible Reporting Entities (RREs) may provide any one of the following to Medicare’s Benefits Coordination & Recovery Center (BCRC) as the beneficiary identifier for MSP reporting purposes:

  • MBI
  • Full SSN
  • HICN or Railroad Retirement Board (RRB) Medicare number

Additional information can be obtained from the CMS website at

CMS Releases NGHP Section 111 User Guide v5.2

CMS has released an updated NGHP User Guide, version number 5.2. The update clarifies MIR Section 111 reporting thresholds initially addressed in a published alert by CMS Financial Services Group posted to the Non-Group Health Plan Recovery site on November 15, 2016 entitled “2017 Recovery Thresholds for Certain Liability Insurance, No-Fault Insurance, and Workers’ Compensation Settlements, Judgments, Awards or Other Payments”. The changes to thresholds are summarized below.

For Section 111 reporting, the Centers for Medicare & Medicaid Services (CMS) has changed the minimum reportable Total Payment Obligation to the Claimant (TPOC) amounts for liability insurance (including self-insurance), no-fault insurance, and workers’ compensation claims.

  • Liability is changing from $1000 to $750 for TPOC Dates of 1/1/2017 and subsequent.
  • No-Fault is changing from $0 to $750 for TPOC Dates of 10/1/2016 and subsequent.
  • Workers’ Compensation (WC) is changing from $300 to $750 for TPOC Dates of 10/1/2016 and subsequent.

TPOC amounts exceeding these thresholds must be reported. However, TPOC amounts less than the specified threshold may be reported and will be accepted.

The logic for the CJ07 error has been changed such that a TPOC of any amount will be accepted for all types of TPOCs, including liability TPOCs. The CJ07 error will continue to be returned for a liability, workers’ compensation, or no-fault claim report where the ORM Indicator is set to “N” and the cumulative TPOC amount is zero.

We are able to provide a consolidated PDF file of all the updated chapters upon request. Please contact us at if you would like to receive this consolidated, searchable file. For more information, please email

MSA Optimism for the New Year

The Centers for Medicare & Medicaid Services (CMS) announced the organization will be reconsidering a new policy in 2017 regarding re-reviews of otherwise approved Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) amounts. According to the CMS announcement, this new policy would only apply to claims “where settlement has not occurred.” As such, if settlement has been agreed upon CMS will not consider a re-review. The timing of any such change, however is yet unknown.

The Centers for Medicare & Medicaid Services recently revisited the task of reviewing its process for addressing requests for CMS to “re-review” otherwise approved Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) amounts. In Calendar year 2017, CMS expects to update its existing re-review process to address situations where CMS has provided an approved amount, but settlement has not occurred and the medical care that supported the approved amount has changed substantially. CMS also expects its updated process to address situations where certain states rely on Utilization Review Processes to justify proposed WCMSA amounts.

At present, CMS provides no formal appeal process. Rather, a one shot re-review process allowing submitters to provide new and different information not previously considered so long as the new and different information predates submission of the case to CMS. Employers, insurers and claimants are also unable to obtain revised MSA approval following a significant change in the claimant’s pre-settlement medical condition.

In addition, CMS will be issuing a policy regarding use of utilization review in MSA submissions in certain states where there is reliance on Utilization Review Processes (UR) to justify proposed WCMSA amounts. Currently, CMS generally recognizes California UR determinations as a limitation on medical care in the MSA if upheld through the statutory Independent Medical Review (IMR) process. Other state UR processes, however, have not been recognized as they are not considered by CMS to be final determinations.

While many states do not rely on UR processes to allocate MSAs, many stakeholders do rely on state law to justify a suggested MSA amount. Unfortunately, CMS policies do not always take into account the statutes used to adjudicate the underlying claim.

A revised MSA re-review process along with an accurate interpretation of state law will allow stakeholders to question the reasonableness of CMS’ counter-higher demands. Such changes will also give stakeholders the opportunity to provide the documentary support needed to explain their proposal and give MSP stakeholders a valid and meaningful appeals process with which to challenge proposed WCMSAs. Whether this announcement will eventually allow for a hearing or a neutral decision maker to review, or other administrative and judicial appellate rights, remains to be seen. Nevertheless, we are optimistic about the potential expansion of the CMS MSA Re-Review process where there has been a substantial change in medical care as this gives insurers, employers and claimants another opportunity to more appropriately settle workers’ compensation claims with open medical benefits. The ability to rely on applicable state statutes during the WCMSA process is similarly encouraging.