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1 Workers' Compensation Medicare Set-Aside Arrangement ( WCMSA ). Reference Guide Version October 5, 2020. WCMSA Reference Guide Table of Contents Table of Contents About This Reference Guide .. 1. Changes in This Version of the Guide .. 1. Introduction to Workers' Compensation and Medicare .. 2. Medicare as Secondary Payer .. 2. Reporting a WC Case .. 2. Past and Future Medical services .. 3. What Are Workers' Compensation Medicare Set-Aside Arrangements? .. 4. Should I Consider Submitting a WCMSA Proposal? .. 5. Considerations and Guidelines .. 5. Commutation and Compromise .. 5. Outstanding WC Claims .. 5. Other Health Coverage .. 5. Hearing on the Merits of a Case .. 5. Indications That Medicare 's Interests are Protected .. 6. WCMSA Funding Structures .. 6. Lump-Sum WCMSAs .. 7. Structured WCMSAs .. 7. Who Can Help with the WCMSA Process? .. 7. How is CMS Approval of a WCMSA Amount Obtained? .. 8.

2 Should CMS Review a WCMSA ? .. 8. Review Thresholds .. 8. WCMSA Submission Process Overview .. 10. WCMSAP Submissions .. 11. Paper or CD Submissions .. 12. Receipt Review .. 12. WCRC Review .. 12. WCRC Review Process .. 12. WCRC Team Background and Resources 13. WCRC Review Considerations .. 14. Medical Review .. 15. Medical Review Guidelines .. 23. Pharmacy .. 27. Regional Office Receipt .. 33. Final Determination .. 33. ii WCMSA Reference Guide Table of Contents Information Needed for WCMSA Submission .. 34. Section 05 Cover Letter .. 35. Section 10 Consent to Release Note .. 41. Section 15 Rated Age Information or Life Expectancy .. 43. Section 20 Life Care / Future Treatment Plan .. 44. Current Treatment .. 45. Future Treatment .. 45. Section 25 Settlement Agreement or Proposed or Court Order .. 47. Indicate How Much of the Settlement is for Past v. Future Medical Expenses .. 47. Use of WC Fee Schedule vs.

3 Actual Charges for WCMSA .. 48. Total Settlement Amount .. 48. Section 30 WCMSA Administration Agreement .. 48. Section 35 Medical Records .. 49. Section 40 Payment History .. 50. Section 50 Supplemental or Additional Information .. 51. How do I submit a WCMSA ? .. 51. Electronic Submission via the WCMSAP .. 51. Benefits of Using the WCMSAP .. 52. Paper Copy/CD Submission via the Mail .. 52. Paper Copy .. 52. CD .. 52. What Happens after a WCMSA Has Been Submitted? .. 53. Sample Submission .. 54. Tips for Improving Your WCMSA Review Process .. 54. Review Process and Policies .. 54. Time Frame .. 55. Criteria .. 55. Compromise of Future Medical Expenses .. 56. No Waivers of Specific services Related to Future Medicals .. 56. Case Status and Communications .. 56. Review Following Conditional Approval .. 57. Re-Review .. 57. Amended Review .. 58. Required Resubmission .. 59. Account Set-Up and Administration.

4 59. Administrators .. 59. iii WCMSA Reference Guide Table of Contents Interest-Bearing Account .. 60. Use of the Account .. 60. Medicare Entitlement and WCMSA .. 60. Loss of Medicare Entitlement after CMS Approval of a WCMSA .. 61. Use of WC Settlement Funds Prior to Medicare Entitlement .. 61. Annual Attestation and Record-Keeping .. 61. Electronic 62. Link .. 62. CMS' Monitoring .. 63. What Happens if Circumstances Change? .. 64. WCMSA is Under-Funded .. 64. Death of the Claimant .. 64. Structured WCMSA Funds Topics .. 64. Funds Left Over/Carried Forward .. 64. Funds Used in a Given Period .. 64. Change of Submitter .. 65. Appendix 1 Contact Information .. 66. Appendix 2 Abbreviations List .. 68. Appendix 3 Glossary .. 70. Appendix 4 WCRC Proposal Review Reference Tools .. 73. Appendix 5 Sample Letters .. 75. Approval Letter .. 75. Zero Set-Aside Letter .. 78. Below Threshold Letter .. 80. Beneficiary Below Threshold Letter.

5 82. Development Letter .. 84. Closeout Letter .. 90. Appendix 6 Sample Submission .. 92. Appendix 6: 05 Cover Letter .. 93. Appendix 6: 10 Consent to Release Note .. 98. Appendix 6: 15 Rated Age Information or Life Expectancy .. 100. Appendix 6: 20 Life Care/Future Treatment Plan .. 104. Appendix 6: 25 Settlement Agreement or Proposed or Court Order .. 106. Appendix 6: 30 WCMSA Administration Agreement .. 110. Appendix 6: 35 Medical Records .. 114. Appendix 6: 40 Payment History .. 127. Appendix 7 Major Medical Centers by State, NPI, and ZIP Code .. 131. iv WCMSA Reference Guide Table of Contents Appendix 8 List of Previous Version Changes .. 177. Figures Figure 9-1: WCMSA Submission Process Overview .. 11. Figure 9-2: WCRC Medical Review Steps .. 16. Figure 10-1: Blank Consent to Release Note .. 42. Figure 10-2: Example Consent to Release with Instructions .. 43. Tables Table 9-1: Verifying Jurisdiction and Calculation Method (Normal Pricing).

6 18. Table 9-2: Verifying Jurisdiction and Calculation Method (Other Pricing) .. 19. Table 9-3: Spinal Cord Stimulator Surgery CPT Codes .. 25. Table 10-1: WCMSA Document Requirements Checklist .. 34. Table Appendix 4-1: WCRC Proposal Review Reference Tools .. 73. Table Appendix 7-1: Major Medical Centers by State, NPI, and ZIP 132. v WCMSA Reference Guide Confidentiality Statement Confidentiality Statement The collection of this information is authorized by Section 1862(b) of the Social Security Act (codified at 42 1395y(b)) (see also 42, ). The information collected will be used to identify and recover past conditional and mistaken Medicare primary payments and to prevent Medicare from making mistaken payments in the future for those Medicare Secondary Payer situations that continue to exist. The Privacy Act (5 552a(b)), as amended, prohibits the disclosure of information maintained by the Centers for Medicare & medicaid services (CMS) in a system of records to third parties, unless the beneficiary provides a written request or explicit written consent/authorization for a party to receive such information.

7 Where the beneficiary provides written consent/proof of representation, CMS will permit authorized parties to access requisite information. vi WCMSA Reference Guide About This Reference Guide This Guide was written to help you understand the process used by the Centers for Medicare &. medicaid services (CMS) for approving proposed Workers' Compensation Medicare Set-Aside Arrangement ( WCMSA ) amounts and to serve as a Reference for those choosing to submit such amounts to CMS for approval. Submitters may include injured workers themselves (claimants), their attorneys, Workers' Compensation (WC) Medicare Set-Aside Arrangement (MSA) agents or consultants, or claimants' other appointed representatives. This Guide reflects information compiled from all WCMSA Regional Office (RO) Memoranda issued by CMS, from information provided on the CMS website, from information provided by the Workers Compensation Review Contractor (WCRC), and from the CMS WCMSA Operating Rules.

8 The intent of this Reference Guide is to consolidate and supplant all historical memoranda in a single point of Reference . Please discontinue the Reference of prior documents. There are no statutory or regulatory provisions requiring that you submit a WCMSA amount proposal to CMS for review. If you choose to use CMS' WCMSA review process, the Agency requests that you comply with CMS' established policies and procedures. Changes in This Version of the Guide Version of this Guide includes the following changes: To define the major medical Centers that the Workers' Compensation Review Contractor (WCRC) uses to estimate future medical expenses in proposed WCMSAs, a list of major medical Centers , organized by state, medical center name, National Provider Identifier (NPI), and ZIP code, has been provided (Section and Appendix 7). 1. WCMSA Reference Guide Introduction to Workers' Compensation and Medicare Medicare as Secondary Payer Medicare Secondary Payer (MSP) is the term used when the Medicare program does not have primary payment responsibility on behalf of its beneficiaries that is, when another entity has the responsibility for paying for medical care before Medicare .

9 Until 1980, the Medicare program was the primary payer in all cases except those involving WC (including Black Lung benefits) or for care that is the responsibility of another government entity. With the addition of the MSP provisions in 1980 (and subsequent amendments), Medicare is secondary payer to group health plan insurance in specific circumstances, but is also secondary to liability insurance (including self-insurance), no-fault insurance, and WC. An insurer or WC plan cannot, by contract or otherwise, supersede federal law, for instance by alleging its coverage is supplemental to Medicare . WC is a primary payer to the Medicare program for Medicare beneficiaries' work-related illnesses or injuries. Medicare beneficiaries are required to apply for all applicable WC benefits. If a Medicare beneficiary has WC coverage, providers, physicians, and other suppliers must bill WC first. In order to comply with 42 1395y(b)(2) and 1862(b)(2)(A)(ii) of the Social Security Act, Medicare may not pay for a beneficiary's medical expenses when payment has been made or can reasonably be expected to be made under a workers' compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance.

10 If responsibility for the WC claim is in dispute and WC will not pay promptly, the provider, physician, or other supplier may bill Medicare as primary payer. If the item or service is reimbursable under Medicare rules, Medicare may pay conditionally, subject to later recovery if there is a subsequent settlement, judgment, award, or other payment. (See 42 for the definition of promptly with regard to WC.). Reporting a WC Case All WC occurrences that involve a Medicare beneficiary should be reported to the Benefits Coordination & Recovery center (BCRC). If you are a Responsible Reporting Entity (RRE). making an initial report of ongoing responsibility, use the Section 111 COB Secure Website for reporting. For the submission of WCMSA information, contact the BCRC by phone or mail. Customer Service Representatives are available Monday through Friday, from 8:00 to 8:00. , Eastern Time, except holidays.