What is a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA)?

What is Included in a WCMSA?

A WCMSA includes the following information:

• Claimant information: Name, address, date of birth, Social Security number, Medicare ID (if applicable)

• Settlement information: Date of injury, type of injury, total settlement amount, proposed WCMSA amount

• Medical information: Medical records, life expectancy information, treatment plan, payment history

• Administration agreement: Information about who will administer the WCMSA account

Who Prepares the WCMSA?

A WCMSA can be prepared by various parties involved in the settlement process, including the attorneys, a workers' compensation insurer, or a WCMSA vendor. Often, attorneys or specialized WCMSA vendors have the expertise to accurately assess future medical costs and prepare the proposal. It is important to choose someone with experience in WCMSA preparation to ensure that the proposal meets CMS guidelines and adequately protects Medicare's interests.

How are Future Medical Expenses Determined?

Determining future medical expenses for a WCMSA is a crucial step in the process. It requires a comprehensive evaluation of the claimant's medical records, treatment history, and future medical needs. This evaluation considers factors such as:

• Past medical payment history: Bills paid by workers' compensation or Medicare in the initial years after the injury can indicate the likelihood of specific future medical expenses.

• Claimant's medical condition: The type and severity of the injury, the expected recovery time, and the possibility of future complications are all considered.

• Life expectancy: CMS uses the Centers for Disease Control (CDC) life expectancy tables to project the claimant's remaining lifespan. Rated ages provided by insurance companies may also be considered.

• Treatment plan: The WCMSA must include a detailed plan outlining the types of medical services, treatments, and medications the claimant is expected to need in the future.

• State laws and regulations: State laws regarding the duration of workers' compensation coverage and any limitations on medical treatment are also considered.

• Medicare coverage guidelines: The WCMSA only includes medical items and services that are covered by Medicare.

  
  

The goal is to create a WCMSA that covers the full cost of all reasonably anticipated future medical expenses related to the work injury for the claimant's lifetime, ensuring Medicare's interests are protected

WCMSA Approval Process:

1. Analysis: A thorough review of the claim and all medical information is needed to determine the amount of money required for the WCMSA.

2. Negotiation: A tentative settlement is reached, and draft settlement documents are prepared, incorporating terms for the creation and administration of the WCMSA. CMS is not involved in the settlement negotiations.

3. CMS Approval: The proposed WCMSA amount is submitted to CMS for approval.

4. Review Thresholds: CMS will review a proposed WCMSA if the claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000, or if the claimant is expected to enroll in Medicare within 30 months and the total settlement amount is greater than $250,000.

5. Submission: WCMSA proposals can be submitted electronically through the WCMSA Portal (WCMSAP) or by mail.

6. Review: The Workers' Compensation Review Contractor (WCRC) reviews the proposal and makes a recommendation to CMS.

7. Determination: CMS issues a determination, which may be an approval, a request for additional information, or a denial.

8. Finalization: Once the WCMSA is approved, the settlement is finalized, and the WCMSA is funded.

Note: CMS approval of a WCMSA is not required, but it is highly recommended. Without CMS approval, Medicare may deny payment for future medical expenses related to the work injury, even if they would ordinarily be covered.