CMS Publishes Version 8.4 of the NGHP User Guide

On April 13, 2026, CMS published Version 8.4 of the Section 111 Non-Group Health Plan (NGHP) User Guide.  The key updates are summarized below.

ORM Termination

Previously, the User Guide specified that an ORM termination date may be reported where the RRE's responsibility had been terminated "per the terms of the pertinent insurance contract, such as maximum coverage benefits."  Version 8.4 expands upon this guidance to explain that an ORM termination date may be reported if the RRE’s responsibility was terminated “per the terms of the pertinent insurance contract, such as maximum coverage benefits or any other reason that is not prohibited by the terms of the insurance contract or applicable state or federal law" (emphasis added).  Version 8.4 also explains: “An insurer’s refusal to accept ORM, or to continue to accept ORM, is a valid ORM termination reason, provided that the refusal is permitted by applicable state or federal law and the terms of the insurance contract.”  This guidance is consistent with prior CMS policy but provides explicit recognition of reporting ORM termination based on an RRE’s termination of benefits.

WCMSA Reporting for Multiple Dates of Incident and Multiple Defendants

Version 8.3 of the User Guide explained that MSA information should be reported under the earliest date of incident if multiple dates of incident are settled in one TPOC with diagnosis codes that apply to all dates of incident.  Version 8.4 clarifies this guidance and specifies that the total MSA amount must be reported in cases involving multiple defendants.  Version 8.4 explains: “As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the earliest date of incident, if only one TPOC is made. If multiple TPOCs are submitted, but only one MSA is reported, the MSA shall be reported on the first TPOC only. Where there are multiple defendants (RREs) reporting each RRE must report the total MSA Amount—not just its assigned or proportionate share. System logic exists such that only the first reported MSA amount will be applied for purposes of coordination of benefits.”

Wrongful Death Claims

Version 8.3 provided: "Settlements, judgments, awards, or other payments obtained entirely under the wrongful death theory of liability, which do not claim and release medicals, or have the effect of releasing medicals, are not required to be reported because Medicare would have no recovery claim against such a payment."  Version 8.4 replaces this statement with the following guidance: "In order for the wrongful death theory of liability to preclude Medicare from recovering from a settlement, judgment, award, or other payment, complete documentation must be provided that shows what was claimed and released or had the effect of being released. Additionally, a citation to the appropriate state statute or case law that precludes recovery from a wrongful death settlement should be included with any such dispute or appeal."  The new language addresses documentation to provide with a conditional payment dispute or appeal, but it underscores that the issue of whether Medicare has an interest in wrongful death settlements depends upon the plaintiff’s allegations, settlement terms, and available damages under state law.

Commission Approvals

The User Guide previously provided that in cases involving court approval, the TPOC Date is “the later of the date the obligation is signed or the date of court approval.”  Version 8.4 adds a reference to workers’ compensation commissions and explains that if court or commission approval is required, the TPOC Date “is the later of the date the obligation is signed or the date of court or commission approval.”

Online EDI Representative Requests

The User Guide now reflects that Section 111 Account Managers and designees can now submit requests to their EDI representative through the Section 111 website.  CMS recently added this feature to provide an additional method for RREs to contact their EDI representative. 

The new User Guide is available at: https://www.cms.gov/medicare/coordination-benefits-recovery/mandatory-insurer-reporting/user-guide.  Please do not hesitate to contact us with any questions.