CMS Announces Changes to WCMSA Reference Guide including Extension of Time Frame for Amended Reviews


CMS recently released an updated version of the Workers’ Compensation Medicare Set-aside Arrangement Reference Guide. The new version of the Reference Guide includes several noteworthy changes.

Importantly, CMS has extended the time frame for the Amended Review process to 6 years. Parties can now request approval of a new MSA amount at least 12 months, but no more than 72 months, after the previous determination was issued. Previously, the time frame was 12 to 48 months. In order to be eligible for the Amended Review process, the new MSA amount must reflect a change of at least 10 percent or $10,000.00 (whichever is greater) from the prior MSA amount. In addition, CMS will deny an Amended Review request when the sole reason for the request is the approval of a generic version of a medication by the FDA. It is important to keep in mind that CMS will only review one Amended Review request per case and CMS will not allow parties to supplement an Amended Review request. Please do not hesitate to contact us about any cases that may be eligible for an Amended Review under the new guidelines. We will be happy to help.

The Reference Guide also includes new requirements for the contents of the consent form from the claimant required for submission of a Medicare Set-aside to CMS for review and approval. The updated language requirements include indication from the claimant that they understand the need for the Medicare Set-aside, the submission process, and approve of the contents of the submission. The new requirements for consent forms will apply to all Workers’ Compensation Medicare Set-asides submitted to CMS beginning April 1, 2020.

The Reference Guide provides new guidance for frequently abused drugs and WCMSA administration programs. The Reference Guide indicates that all WCMSA administration programs should include Drug Management Programs for claimants at risk for abuse or misuse of frequently abused drugs. Drug Management Programs have specific guidelines set out in federal regulations and are currently utilized by Medicare Part D sponsors to address overutilization of drugs defined by CMS as frequently abused drugs. The Reference Guide states that “CMS highly recommends professional administration where a claimant is taking controlled substances that CMS determines are ‘frequently abused drugs’” and generally recommends consideration of the use of a professional administrator for Medicare Set-asides.

CMS also updated the Reference Guide to address the electronic submission of attestation forms. Recently, CMS began allowing Medicare beneficiaries who self-administer WCMSAs to submit their annual and final attestation forms online at www.mymedicare.gov. Professional administrators may now submit attestation forms online through the WCMSA Portal.


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