New WCMSA Reference Guide Summary
Jesse Hamby
April 15, 2013

The attached Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide has been posted to the CMS.gov webpage.  This reference guide was created to help explain the WCMSA approval process and to serve as a reference guide for those electing to submit their WCMSAs to CMS for approval.

The reference guide consolidates information currently found within the Workers’ Compensation Agency Services web pages and CMS Regional Office Program Memorandums, while providing WCMSA information to attorneys, Medicare beneficiaries, claimants, insurance carriers, representative payees, and WCMSA vendors.  CMS also advised that they are going to redesign and restructured their web site.

Below are some sections included within the reference guide.

  • Reporting a WC Case (section 2.2)
    • This section goes over how to report a WC case to the COBC along with what information that the COBC will request.
  • What are Workers’ Compensation Medicare Set-Aside Arrangements? (section 3.0)
    • This section goes into a long explanation of what a WCMSA is.
  • Should I consider submitting a WCMSA proposal (section 4.0)
    • This section goes over considerations and guidelines and notes that CMS approval of a proposed WCMSA amount is not required.  It further states it is unnecessary to obtain CMS approval when all of the following are true:
      • The injured individual is only being compensated for past medical expenses;
      • No evidence that the individual is attempting to maximize the other aspects of the settlement (e.g., the lost wages and disability portions of the settlement) to Medicare’s detriment; and
      • The individual’s treating physicians conclude (in writing) that the individual will no longer require any Medicare-covered treatment(s) related to the WC injury.
  • WCMSA’s can be funded in two ways: a lump sum or structured payments (section 5.0)
  • Should CMS review the WCMSA (section 8.0)
    • This section goes over when Medicare will review a proposed WCMSA and discusses their workload review thresholds.
    • It also states that “if an individual’s WC settlement does not meet the current workload review thresholds, CMS will not issue responses indicating that the review criteria have not been met.”
    • Claimants must still consider Medicare’s interest in all WC Cases and ensure that Medicare pays secondary to WC.
  • WCMSA submission process overview (section 9.0)
    • You can currently submit a WCMSA to CMS by either:
      • Paper submission through the mail with records that are in paper  format or burned to a CD
      • Online via WCMSA Portal – this method has existed since November 2011.  Case information is electronically transmitted to the CMS system used to report and track WCMSA cases. The portal is the preferred method to submit a WCMSA for review and approval.  The portal allows you to check current status, receive development alerts via email and request that the submission be re-reviewed.
  • Information needed for a WCMSA submission (section 10.0)
    • Section 10.0 goes into detail about what items are required and optional when preparing and submitting a WCMSA to CMS.
  • The guide also provides further insight as to CMS’ view of Independent medical evaluations (IME). The guide states that an IME is not a treatment record, nor are invoices or insurance forms. They further state that these items may be appropriate to determine future treatment under certain circumstances, but are not appropriate as medical records (see section 10.1.7).
  • Sample Submission Package (section 13.0)
  • Review process and policies (section 15.0)
    • CMS states that they “try to review and decide on proposed settlements within 45 to 60 days from the time all relevant documents are submitted”
  • WCMSA Re-Review (section 16.0)
    • This sections of the guide discusses how and when to submit a re-review request when you disagree with the CMS’ determination.

The reference guide also includes CMS contact information, abbreviations & glossary listing, WCRC proposal review reference tools used by the WCRC and lastly provides a sample submission packet.

Final Assessment:  The WCMSA Reference Guide does not change any prior policy of CMS with respect to WCMSAs.  It simply represents a consolidation of previously published materials into a concise and easy to access format.