CMS Issues New WCMSA Reference Guide and Self-Administration Toolkit
by B. Smith
This week, the Centers for Medicare & Medicaid Services (CMS) updated their WCMSA Reference Guide and Self-Administration Toolkit. Below is a summary of the pertinent updates.
WCMSA Reference Guide Version 4.3
CMS added a new Notice of Settlement Received Letter in Appendix 5 of the Guide, which states that when a Notice of Settlement that includes WCMSA information is received CMS will update its system to reflect that the WCMSA will be used to pay for injury-related medical treatment. CMS also offers guidance on how the funds should be utilized by the beneficiary and provides a packet of information including annual attestation statements. CMS notes that once the WCMSA funds have been properly exhausted, and Medicare has been given proof that the funds were properly spent, Medicare will begin paying for injury-related medical expenses.
Section 16.3 was updated to remove the one-year waiting period for submission of Amended Reviews. Specifically, parties will not have to wait a year from the approval of the WCSA to submit an Amended Review and can do so at any time after receiving the WCMSA from CMS. However, the rest of CMS’ Amended Review requirements remain unchanged, and organizations still only get one opportunity to request an Amended Review.
CMS also updated policies surrounding change of submitter requests in Section 16.3 and 19.4. CMS confirmed in Section 16.3 that a change of submitter is not a sufficient ground to request an Amended Review. In Section 19.4, CMS indicated that a change of submitter requires both a written withdrawal by the current submitter and a Consent to Release signed by claimant that lists the new submitter. A change of professional administrator requires the new administrator (who does not have the same EIN) to contact the BCRC to gain access to the case via the WCMSA portal. The new administrator can also be submitted by mail. CMS also notes that it will not provide copies of existing documentation to the new submitter.
Self-Administration and You: A Beneficiary Toolkit for Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs)
To provide further clarification regarding the Self-Administration of WCMSA funds, CMS released an updated Toolkit version 1.7. This version contains a more detailed explanation of WCMSAs, requirements for payment of medical expenses from an WCMSA account, and resources for beneficiaries. CMS also removed a prior section on inheritance contained in Section 1.6.
Final Thoughts
In response to the new requirement for reporting of WCMSA information as part of Section 111 Mandatory Insurer Reporting, CMS continues to update resources for beneficiaries and insurers offering guidance and clarification on WCMSA requirements, administration, and tracking. There are a few important things to note as part of these efforts. First, reporting WCMSA information to CMS as part of settlement did not, and does not, change the fact that submission of a WCMSA is voluntary. What is required is a reasonable consideration of Medicare’s interest. Second, Responsible Reporting Entities (RREs) need to ensure that accurate WCMSA information is submitted to CMS to prevent potential False Claim Act exposure and impact on the beneficiary when they utilize the WCMSA funds. Third, regardless of whether you submit an above threshold WCMSA for review or not, if the claimant does not expend their MSA funds appropriately, CMS will not pay for injury-related medical treatment once the funds are exhausted. Funds must be tracked and only used for injury-related Medicare items. Administration of the WCMSA should be seriously considered as part of settlement to prevent future exposure and improper fund expenditures. This can be done through self-administration with support or professional administration. If professional administration is utilized, it is also important that it lasts for the life of the claimant rather than for a limited time that has no bearing on the right for CMS to recover funds or deny treatment for the claimant’s injury-related medical treatment.
If you have any questions about the new WCMSA guide or the updated self-administration toolkit, or would like more information about IMPAXX’s MSA offerings, post-settlement administration, or Section 111 services, please contact our Settlement Consulting team at [email protected].