CMS Releases Updated WCMSA Reference Guide

The Centers for Medicare and Medicaid Services (CMS) has released an updated Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide (Version 4.1, August 1, 2024).

Specifically, CMS updated Section 4.1.3 to provide further details regarding CMS’s communication and coordination with other health coverage, as well as CMS’s expectations regarding the responsibility of the various parties to ensure that the MSA funds are spent appropriately.

First, CMS advises that they will notify Medicare Advantage (Part C) and Prescription Drug (Part D) plan sponsors when an MSA has been approved. Per the updated Section, CMS instructs the plan sponsors to conduct the necessary investigations, as CMS does not relay specific details of the MSA to the plan sponsors. CMS makes it clear that they expect the plan sponsors to obtain MSA coverage details from the MSA’s administrator, so that they may avoid paying for expenses that should be covered by the MSA.

The updated Section also notes that, when a workers' compensation settlement is reached, the details of the settlement should dictate the party responsible for ensuring that Medicare (Parts A, B, C, and/or D) is reimbursed for any conditional payments made for the work-related illness or injury. Importantly, CMS advises that, if the settlement does not specify funds for past debts, CMS will consider the workers' compensation insurer responsible for such debts up to the settlement date. CMS then warns that recovery of inappropriate payments may be sought from any party that received such payments on behalf of the beneficiary.

Lastly, CMS advises that the MSA administrator must provide details concerning treatments and medications used exclusively to treat the related illness or injury to the plan sponsor. This information helps the plan sponsor avoid making primary payments in the future, ensuring that the WCMSA funds are properly utilized before Medicare benefits are accessed, including those benefits administered by a Medicare Advantage (Part C) and/or Prescription Drug (Part D) plan.