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Montana Self Insurers' Association

December 2025 Update

  • National Council of Self Insurers Annual Conference - Call for Speakers
  • MSIA Participates in UWC Meeting with CMS Leadership
  • New MSA Reporting Guideline – Effective Nov 18
  • CMS Releases Fiscal Year MSA Statistics
  • CMS Announces Webinar on Civil Monetary Penalties – Jan 15
  • Welcome New Member – CBCS Claims

When I started drafting this UPDATE, I swear it was not intended to be ALL CMS, ALL of the TIME. But, that’s how the news in WC unfolded the last few weeks.


The National Council of Self Insurers

Annual Conference is set for May 31 – June 3 - at the incredible Ritz Carlton in Rancho Mirage CA. (MSIA is a member of the Board of Directors for the National Council and is part of the Conference Committee)

This Conference will see some of the nation’s top leaders and speakers addressing the issues we all face in workers’ compensation. The real value of the National Council Annual Conference is Employers Talking With Employers about what’s working, what’s next and what they’ve learned in trying different approaches as we try to eliminate accidents and help injured workers return to life after an accident has happened. As well, the Conference is designed to be an intimate gathering, providing greater opportunity to network and discuss issues with peers and leaders. The Conference Call for Speakers is out - -  NCSI 2026 Conference Speaker Application

MSIA members, as leaders in our business have been well represented in the past – Sibayne Stillwater, Midland Claim Service, EK Health, Sanderson Firm, MinWorx Health, Rx Bridge, Allan Koba Compliance Solutions, MyMatrixx, Safety National, Bardavon Health and Paradigm have all been speakers in the past. We’ve learned about:

  • AI in our business and our world,
  • Un-bundling claim management contracts for better results,
  • The latest in risk, safety and claims management and
  • How unique situations, sometimes require unique solutions – which sometimes can be used elsewhere.

Each participant brought their knowledge, expertise and background – and their relationships – to help all of us understand more about our business. The National Council Annual Conference is an important opportunity to learn from the best in class, reconnect with peers, make new connections, network and enjoy the company of professionals from across the country. This is not like other conferences with thousands in attendance. This is a purposefully limited conference to provide the greatest opportunities to connect and learn. And, it is always in an absolutely fabulous setting providing for great opportunities for the family as well. 

The annual call for speakers has been released: NCSI 2026 Conference Speaker Application. We require that if a service provider wants to present, that an employer accompany them and share their perspectives. National Council speakers are names you know – Walt Disney, Walmart, Sunbelt Rentals, JM Smucker, Fanactics and more. Not all applicants are accepted – there are limited speaking opportunities available. You and your company should be on that list.

The speaker application deadline is January 9, 2026. This is a Conference you do not want to miss.

 

 MSIA Participates in UWC Meeting with CMS Leadership

As part of the National Council of Self Insurers, MSIA is on the Board of Directors for UWC Strategies. UWC is another national business group working on Unemployment and Workers Compensation issues at the federal level. UWC arranged for a Sept 30 meeting with the new CMS leadership in the Trump administration where there was some interesting dialogue regarding potential changes to the MSA process (see the MSIA October 2025 UPDATE). UWC again arranged a meeting with the CMS leadership on Dec 2, where MSIA was the only WC expert and was requested to comment on each agenda item.

The agenda included :

  • Life Expectancy/Rated Age/Duration Limitations
  • Duration of Medical Treatment for WC Injuries
  • Prescription Drug Pricing
  • Allocation of Costs in WC Settlements
  • Maintenance of MSA Accounts/Direct Payments
  • Appeals

The first two issues really deal with the difference in approach between CMS and individual state workers’ compensation programs. Some states have duration of treatment limitations for workers’ compensation claims. CMS currently ignores those possibilities and calculates MSAs based on either the Table 1 Medicare life expectancy or an acceptable Rated Age submission. CMS indicated a willingness to review their internal agency operational policy, and therefore direction to contractors, regarding the potential of applying a more limited lifetime duration for WC MSAs.

Part of the sticking point may be in the process. CMS requires a settlement approval from a Court of Competent Jurisdiction or a regulatory body to identify the potential limitation within the state law. However, settlement negotiations are conducted and MSAs are necessary to be calculated into the settlement amounts, before agreement – and approval by either the Court or (in MT) the Department of Labor. However, that CMS is willing to consider a different approach, is a step in the right direction.

On Prescription drugs, CMS has a tougher time. They are asked to predict the future and have taken the position of projecting the past in a straight line for the remainder of the life of the beneficiary. While a lifetime expectation may change based on the above issue and effective treatment, knowing how to predict when a treatment pattern will change is a bit more difficult. CMS does not have access to (nor are they necessarily entitled to) the medical treatment program nor prognosis. WC typically works on the assumption that injured workers will heal and the treatment program will change as that happens. CMS does not have access to that information and therefore does not have any basis to predict the future, other than the past treatment information. We will continue to discuss how we might be able to address this issue.

On the allocation of costs in a WC settlement CMS again somewhat strapped. They can use a Court or Regulatory approved settlement document for allocation of costs – but that happens after the MSA is produced and the settlement agreed to. As well, for those non-liability settlements CMS sometimes receives a $1 allocation for future medical – which works for settling purposes but does not work for CMS purposes. We will continue to discuss how we might be able to address this issue.

On Direct Payments, CMS at the September 30 meeting indicated they were willing to look at the issue – which was a significant departure from past communications. If we can do something on this issue, that can have a significant impact on CMS efficiency as well as benefitting payers and beneficiaries/injured workers. CMS staff identified they did not necessarily have an issue with the concept but were barred from accepting funds for future liabilities or liabilities that may not occur based on the Anti-Deficiency Act. To move forward on this issue, they indicated a statutory change would have to occur.

We ran out of time to discuss appeals from CMS WC MSA decisions. MSIA was also only able to make a 30 second comment on the new Non-Group Health Plan (WC and other liability coverages) claims reporting Guidelines that were released in November. However, UWC followed up in writing with the CMS leadership expressing our concerns. Other groups are meeting with CMS on this change as well, within the next couple of weeks.

 

New MSA Reporting Guideline Effective Nov 18

CMS released version 8.2 of the NGHP (Non-Group Health Plan) User Guide – the reporting requirements for workers’ compensation and other liability coverages to CMS regarding claims from people who are or are soon to be Medicare eligible. New, detailed guidance clarifies how to report a single settlement (Total Payment Obligation to Claimant -TPOC) or Medicare Set-Aside (MSA) that resolves multiple claims with different Dates of Incident (DOI). You must now report the information for all claims being settled with the earliest DOI and include all diagnosis codes - a significant shift in reporting. MSIA had about 30 seconds at the December 2 meeting to bring this issue up. As a result there was not discussion on it.

In the November 18 release, which is in effect, the new Version 8.2 of the NGHP User Guide | CMS is the new language of 6.5.1.3:

  • Single settlement resolving multiple incidents (different Dates of Incident) – Where there are multiple incidents (multiple dates of incident) being resolved with one TPOC (Total Payment Obligation to Claimant), the RRE (Responsible Reporting Entity – the employer) shall report the earliest date of incident and include all diagnosis codes being settled for all dates of incident. This applies regardless of the timing of the subsequent dates of incident, the nature of the injuries, or any allocation made to each date of incident in the settlement documents. This ensures that all medicals that were released by the settlement are accurately recovered while still affording the beneficiary a dispute and administrative appeal process if any claims are erroneously identified.
  • Medicare Set-Asides – As it relates to multiple dates of incident, an MSA, if applicable, shall be reported under the same guidance as above. That is, 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 in this scenario, the same guidance applies to MSAs as it does to TPOCs.

Here’s an example that may illustrate our concerns with this direction:

2005 Carpal Tunnel claim. Surgeries paid for. Total medicals paid exceeds $25k. Lifetime medical state - so cannot report ORM (Ongoing Responsibility for Medical) termination date even though last treatment was in 2007. We need to note that some state WC laws – like Montana - do NOT provide for lifetime medical for perm partial injuries. MT WC system benefits terminate after 5 years from date of injury, unless continued treatment is necessary for return to or stay at work, or there is agreement between the employer and the injured worker to continue benefits.

2015 lower back claim – permanent aggravation to a pre-existing condition. Claimant has long standing pre-existing cervical spine condition with multiple surgeries (2008, 2009, 2012) prior to our 2015 claim that Medicare correctly paid for.

2025 Insurer ready to settle claim, claimant no longer works for employer. Get an MSA, settle all claims (2005 AND 2015) for $100k with an MSA amount of 80k.

Since we settled the claim, we now enter settlement date 2025 as ORM termination date on both carpal tunnel and lower back claim.

This new language is that we should now include the lower back claim diagnoses to the 2005 Carpal Tunnel claim Section 111 Reporting, then enter the $100k TPOC / $80k MSA on the 2005 carpal tunnel claim and leave it completely off the 2015 Lower back claim. As a result,

  • The record looks like ORM spans 2005 date of injury for the lower back
  • Historically this means Medicare now searches for lower back treatments that may have occurred during the time frame of ORM (in this example - 2005-2025).
  • Here’s the curve ball, the claimant had three c-spine surgeries between 2005 and when our lower back liability started in 2015. 

CMS will now receive updated ORM termination date AND new diagnoses AND TPOC/MSA field information on the 2005 claim. What kind of process will they have to NOT to assert liens for the three surgeries and other treatment unrelated to our lower back claim prior to 2015?

Will CMS be able to segregate the data from unrelated treatments from the information they are asking for, in the formats they are asking for it? If not, we’ll have a whole new industry of attorneys working to untangle data and conditional lien requests from unrelated claims or liabilities.

CMS is asking us to provide unrelated information on the earliest reported claim. While the beneficiary/injured worker is the same, the injuries and liabilities are not. This may be a very efficient way to create chaos. MSIA made this point, although in the last minute of the meeting with CMS on 12/2. Other industry groups are also scheduled to meet with CMS leadership and will be making the same points.


CMS Releases Fiscal Year MSA Statistics

The day before Thanksgiving, CMS released its fiscal year statistics regarding MSAs - WCMSA Fiscal Year Statistics 2020-2024 (WCRC = Workers’ Compensation Review Contractor)

I guess the good news is that the number of MSAs submitted and reviewed continues to go down from a high in 2023 of 15,743 to the current FY of 13,884. There can be a number of reasons for this including the continued decrease in claims (one has to be able to dream…). CMS also stopped accepting or reviewing $0 MSA submissions in July 2025 and that could have an impact on these numbers. However, there is more likely a greater sophistication of MSA reporters and their decisions to manage MSA levels on their own.

This last point may be bolstered by the continued increase in recommended amounts of MSAs from those initially proposed. The difference this year is a 24 % increase in the MSA level recommended by CMS contractors versus that submitted for review. The good news there is that the CMS contractor recommended dollar amounts on average, are relatively flat (even though they are on average 24% higher than proposed by the payers). The average increase in WCRC recommendations versus proposed MSAs has pretty consistently gone up. There is some speculation that the CMS contractors are taking a more conservative approach to protecting the Medicare Trust Fund by requiring higher MSA amounts than proposed.

 

CMS Announces Webinar on Civil Monetary Penalties – Jan 15

MSIA Member The Sanderson Firm, provided the following information in their Blog this week: CMS will be hosting a webinar regarding CMPs for the NGHP Responsible Reporting Entities (RREs). The presentation by CMS will include reminders about the Final Rule and auditing process, anticipated correspondence, and a question-and-answer session.

RREs (Responsible Reporting Entities – the employers) are encouraged to submit questions in advance of the webinar to the dedicated resource mailbox at Sec111CMP@cms.hhs.gov.

Date: January 15, 2026

Time: 1:00 PM EST (11AM MST)

                             Webinar Link: Click Here

Meeting ID: 239 946 838 195 93

Passcode: eD6Ep6E9

Connect via telephone: (888) 588-2610, United States (Toll-free)

Phone conference ID: 167 106 458#

This will be a different topic than the CMS webinar covering WCMSA Section 111 Mandatory Insurer Reporting that was cancelled because of the government shutdown in October, but a webinar covering CMPs (Civil Monetary Penalties) is welcome given that CMS began auditing workers’ compensation, general liability, and no-fault claims payers for noncompliance with Section 111 Medicare Reporting requirements on October 11, 2025. [Ed. Note – this ties in well with the changes in NGHP Reporting from the story above.]

MSIA intends to participate in this Webinar and will be reporting to members.

 

 Welcome New MSIA Member CBCS Claims

CBCS Claims offers a better experience from a national Third Party Administrator (TPA). Our dedicated and centralized approach helps us deliver one of the most effective and responsive National TPA models in the industry. CBCS’s inclusive claims management approach ensures we consult and seek agreement with our clients – working together to control the total cost of loss. CBCS observes stringent performance and communication standards to ensure all parties remain informed (knowledgeable) throughout the entire claims process, understanding that timely communication drives better outcomes.

At CBCS Claims we strive for excellence, offering regular technical and professional development opportunities for our team. Why is this good for our clients? Because when you have a quality team, you get quality results. CBCS’s technology solutions provide our clients the ability to collect, track and manage data across the full spectrum of the claims management process. We understand that information fuels informed decisions, so we put the right tools and data in your hands to drive better business decisions.

The CBCS experience is defined by the personal encounters with our clients. Our clients not only receive first-rate consultative advice and service, but most importantly, they trust us as a partner in their business – sitting on the same side of the table, solving problems and delivering measurable results. To learn more about CBCS Claims contact Julie Bandy at JBandy@CBCSClaims.com or call at 563.587.5247.Add newsletter content here.