CMS Implements $750 Settlement Threshold for WC Conditional Payment Recovery; Maintains $1,000 Threshold in Liability


A September 26, 2016 CMS Alert (Alert) announced the implementation of a $750 conditional payment recovery threshold for no-fault and workers’ compensation settlements.  CMS also announced it is maintaining the $1,000 conditional payment recovery threshold for liability settlements, a threshold which has been in place since January 1, 2014.


Workers’ compensation and no-fault plans are no longer required to report settlements through Section 111 Mandatory Insurer Reporting of $750 or less.  Further, CMS will not seek to recover conditional payments on settlements of $750 or less.  This threshold does not impact the workers’ compensation and no-fault plan’s responsibility to report the acceptance of injury-related medical care as Ongoing Responsibility for Medical (ORM) through the Section 111 reporting process and to terminate ORM when appropriate, usually upon settlement of medicals.  It also has no impact on CMS’s Commercial Repayment Center (CRC) seeking reimbursement from workers’ compensation and no-fault plans on injury-related medical care incurred prior to ORM termination.

In regard to liability settlements, CMS reiterates the $1,000 threshold is applicable to physical trauma-based settlements, not settlements for alleged ingestion, implantation or exposure.

The Alert can be found here.

Information on the methodology used to determine the thresholds can be found here.