Workers’ Compensation MedicareSet-Aside Arrangement (WCMSA)Reference GuideVersion 3.3April 19, 2021COBR-Q2-2021-v3.3

WCMSA Reference GuideTable of ContentsTable of Contents1.0About This Reference Guide . 11.12.0Changes in This Version of the Guide. 1Introduction to Workers’ Compensation and Medicare. 22.1Medicare as Secondary Payer . 22.2Reporting a WC Case . 22.3Past and Future Medical Services. 33.0What Are Workers’ Compensation Medicare Set-Aside Arrangements?. 44.0Should I Consider Submitting a WCMSA Proposal? . 55.04.1Considerations and Guidelines . 54.1.1 Commutation and Compromise . 54.1.2 Outstanding WC Claims . 54.1.3 Other Health Coverage . 54.1.4 Hearing on the Merits of a Case . 54.2Indications That Medicare’s Interests are Protected . 6WCMSA Funding Structures . 65.1Lump-Sum WCMSAs . 75.2Structured WCMSAs . 76.0Who Can Help with the WCMSA Process? . 77.0How is CMS Approval of a WCMSA Amount Obtained? . 88.0Should CMS Review a WCMSA? . 88.19.0Review Thresholds . 8WCMSA Submission Process Overview . 109.1WCMSAP Submissions .119.2Paper or CD Submissions .129.3Receipt Review .129.4WCRC Review .129.4.1 WCRC Review Process .129.4.2 WCRC Team Background and Resources Used .139.4.3 WCRC Review Considerations .149.4.4 Medical Review .159.4.5 Medical Review Guidelines .239.4.6 Pharmacy .279.5Regional Office Receipt .339.6Final Determination .33ii

WCMSA Reference GuideTable of Contents10.0 Information Needed for WCMSA Submission . 3410.1 Section 05 – Cover Letter .3510.2 Section 10 – Consent to Release Note .4110.3 Section 15 – Rated Age Information or Life Expectancy .4310.4 Section 20 – Life Care / Future Treatment Plan .4410.4.1 Current Treatment .4510.4.2 Future Treatment .4510.5 Section 25 – Settlement Agreement or Proposed or Court Order .4710.5.1 Indicate How Much of the Settlement is for Past v. Future MedicalExpenses .4710.5.2 Use of WC Fee Schedule vs. Actual Charges for WCMSA .4810.5.3 Total Settlement Amount .4810.6 Section 30 – WCMSA Administration Agreement.4810.7 Section 35 – Medical Records .4910.8 Section 40 – Payment History .5010.9 Section 50 – Supplemental or Additional Information .5111.0 How do I Submit a WCMSA? . 5111.1 Electronic Submission via the WCMSAP .5111.1.1 Benefits of Using the WCMSAP .5211.2 Paper Copy/CD Submission via the Mail.5211.2.1 Paper Copy .5211.2.2 CD.5212.0 What Happens after a WCMSA Has Been Submitted? . 5313.0 Sample Submission . 5414.0 Tips for Improving Your WCMSA Review Process . 5415.0 Review Process and Policies . 5415.1 Time Frame .5515.2 Criteria .5515.2.1 Compromise of Future Medical Expenses .5615.2.2 No Waivers of Specific Services Related to Future Medicals.5615.3 Case Status and Communications .5616.0 Review Following Conditional Approval. 5716.1 Re-Review .5716.2 Amended Review.5816.3 Required Resubmission .5917.0 Account Set-Up and Administration . 5917.1 Administrators .59iii

WCMSA Reference GuideTable of Contents17.2 Interest-Bearing Account .6017.3 Use of the Account .6017.4 Medicare Entitlement and WCMSA .6017.4.1 Loss of Medicare Entitlement after CMS Approval of a WCMSA .6117.4.2 Use of WC Settlement Funds Prior to Medicare Entitlement.6117.5 Annual Attestation and Record-Keeping .6117.6 Electronic Attestation .6217.7 Link .6218.0 CMS’ Monitoring . 6319.0 What Happens if Circumstances Change? . 6419.1 WCMSA is Under-Funded .6419.2 Death of the Claimant .6419.3 Structured WCMSA Funds Topics .6419.3.1 Funds Left Over/Carried Forward .6419.3.2 Funds Used in a Given Period .6419.4 Change of Submitter .65Appendix 1 Contact Information .66Appendix 2 Abbreviations List .68Appendix 3 Glossary .70Appendix 4 WCRC Proposal Review Reference Tools .73Appendix 5 Sample Letters.75Approval Letter .75Zero Set-Aside Letter .78Below Threshold Letter.80Beneficiary Below Threshold Letter .82Development Letter .84Closeout Letter .90Appendix 6 Sample Submission .92Appendix 6: 05 – Cover Letter .93Appendix 6: 10 – Consent to Release Note .98Appendix 6: 15 – Rated Age Information or Life Expectancy .100Appendix 6: 20 – Life Care/Future Treatment Plan .104Appendix 6: 25 – Settlement Agreement or Proposed or Court Order .106Appendix 6: 30 – WCMSA Administration Agreement .110Appendix 6: 35 – Medical Records .114Appendix 6: 40 – Payment History.127Appendix 7 Major Medical Centers by State, NPI and ZIP Code .131iv

WCMSA Reference GuideTable of ContentsAppendix 8 List of Previous Version Changes .177FiguresFigure 9-1: WCMSA Submission Process Overview .11Figure 9-2: WCRC Medical Review Steps .16Figure 10-1: Blank Consent to Release Note .42Figure 10-2: Example Consent to Release with Instructions.43TablesTable 9-1: Verifying Jurisdiction and Calculation Method (Normal Pricing) .18Table 9-2: Verifying Jurisdiction and Calculation Method (Other Pricing) .19Table 9-3: Spinal Cord Stimulator Surgery CPT Codes .25Table 10-1: WCMSA Document Requirements Checklist .34Table Appendix 4-1: WCRC Proposal Review Reference Tools.73Table Appendix 7-1: Major Medical Centers by State, NPI, and ZIP Code .132v

WCMSA Reference GuideConfidentiality StatementConfidentiality StatementThe collection of this information is authorized by Section 1862(b) of the Social Security Act(codified at 42 U.S.C 1395y(b)) (see also 42, C.F.R. 411.24). The information collected will beused to identify and recover past conditional and mistaken Medicare primary payments and toprevent Medicare from making mistaken payments in the future for those Medicare SecondaryPayer situations that continue to exist. The Privacy Act (5 U.S.C. 552a(b)), as amended, prohibitsthe disclosure of information maintained by the Centers for Med