Updated Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide Released by CMS


The Centers for Medicare and Medicaid Services (CMS) recently released an updated version of the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide. The most recent version, Version 3.3, clarifies a number of issues, including the requirement for initial deposit funds in a structured Medicare Set-aside.


The recently revised reference guide now specifies that in a structured WCMSA, “an initial deposit is required to cover the first surgery or procedure for each body part, and/or replacement and the first two years of annual payments.” This is a change from prior versions of the reference guide, which only specified that funds for the first surgery or procedure would be required. The enforcement of this change from including funds for a single surgery or procedure to the cost of the first surgery or procedure for each body part will inflate the required seed money in many set-asides.


CMS also added a specification in the revised reference guide to the section regarding the requirements for the consent to release used in CMS submission. Version 3.3 now clarifies that the consent to release form used in CMS submission must be hand or electronically signed with the full name of either the claimant, matching the claimant’s legal name, or by the claimant’s authorized representative, if documentation establishing the relationship is also provided. This provision also specifies that the consent to release must be signed with a full signature and that initials will not be accepted. Please note that this provision does not appear to apply to the statement of understanding of the submission process., which is also required on the consent to release form. Initials will still be accepted for the statement of understanding.


The revised reference guide also includes the following changes:

  • An updated link to the 2018 life tables. As we noted here, CMS recently began using the CDC’s “Table 1: Life Table for the total population: United States, 2018” for Workers’ Compensation Medicare Set Aside life expectancy calculations. The 2018 table may be found at: Table 1: Life Table for the total population: United States, 2018

  • An added program to the list of WCRC proposal review reference tools. The newly added program, Conduent Strataware, is a tool for repricing medical bills to state-mandated fee schedules, as well as usual, customary and recommended (UCR) rates. In the same section, CMS also included a new disclaimer noting that they do not endorse any of the listed products in reference to their list of WCRC proposal review reference tools.

  • Clarification regarding the pricing of intrathecal pain pumps. Specifically, CMS noted that pricing should include necessary pump refills over the claimant’s life expectancy.

  • A new instruction for change of submission involving professional administrators. The new reference guide now notes that when there is a change of submission involving a professional administrator whose EIN does not match the EIN of the original submitter, the professional administrator may contact BCRC to gain access to the case via the WCMSA Portal; otherwise the submission must be done by mail.

  • An update to the Major Medical Centers table for Missouri.

A link to Version 3.3 of the WCMSA Reference Guide can be found at https://www.cms.gov/files/document/wcmsa-reference-guide-version-33.pdf. As always, if you have any specific questions regarding the changes to the WCMSA Reference Guide or any Medicare Compliance questions in general, please do not hesitate to reach out. We are always happy to help!



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