CMS Releases WCMSA Reference Guide v4.1 and Self-Administration Toolkit v1.6

by D. Dietz

CMS recently published Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide version 4.1, which is now available in the Download section of the Workers’ Compensation Medicare Set Aside Arrangements page on CMS.gov. In addition, CMS released the Self-Administration Toolkit, version 1.6.

Pertinent changes to the Guide include an update to Section 4.1.3 regarding notification to Medicare Part C and Part D plan sponsors. It states in part as follows:

CMS notifies Part C and D plan sponsors that a WCMSA has been approved and instructs plan sponsors to conduct Medicare Secondary Payer (MSP) investigations. However, CMS does not relay WCMSA details to plan sponsors. Instead, CMS instructs plan sponsors to seek WCMSA coverage details from the WCMSA administrator as part of the plan sponsor’s investigation. When possible, Part C and D plan sponsors are required to avoid paying for expenses that should be covered by a WCMSA. When a settlement is reached, the settlement details dictate who is responsible for ensuring Medicare (Parts A, B, C, and/or D) is repaid for any conditional payments associated with the WC illness or injury. If the settlement does not identify funds for past debt, CMS considers those debts up to the date of settlement to belong to the WC insurer. Recovery may be sought from any party receiving inappropriate payment on behalf of the beneficiary. The administrator must provide details concerning treatments and medications used exclusively to treat a related illness or injury to the plan sponsor so the sponsor may avoid making primary payment in the future.

This language was also noted in Section 4 of the Self-Administration Toolkit. In Section 8 of the Toolkit, CMS reminds beneficiaries of the requirement to complete annual attestation statements regardless of the type of Medicare plan they have whether traditional Medicare, a Medicare Advantage Plan, and/or a prescription drug plan.

These updates are significant for several reasons. First, CMS notes that Part C and D plans get notice of the existence of the WCMSA, but it is up to the plan to investigate coverage and WCMSA amounts to avoid improper payment. Second, settlement details dictate who is responsible for conditional payment reimbursement but when not addressed in the settlement, CMS assumes that the insurer is responsible. CMS again states that recovery can be sought from any party receiving inappropriate payment on behalf of the beneficiary. Defendants should confirm that liens will be identified and resolved properly in the settlement. This not only includes traditional Medicare, but Medicare Advantage and Part D plan resolution as well. The query process can identify potential lienholders, but the lien also needs to be investigated and potential disputes addressed.

IMPAXX has saved our customers millions of dollars disputing liens and can investigate all potential lienholders to help confirm that the parties are compliant with Medicare requirements. If you have questions regarding these updates or would like to find out more about our lien resolution services, please contact the Settlement Consulting team at [email protected].