CMS Issues New WCMSA Reference Guide 3.0

From new language added to Consent to Release forms to a focus on professional administration, CMS’ new User Guide contains some important substantive and procedural changes.

Recommended Professional Administration of WCMSA Accounts:

Section 17.1 has been updated to include Medicare’s recommendation to professionally administer MSA’s that include “Frequently Abused Drugs” as defined by CMS’ Part D Drug Utilization Review Policy. A link to the policy can be found below.  Medicare highly recommends professional administration when these frequently abused drugs are a part of the MSA:

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/RxUtilization.html

Section 17.6 was changed to Electronic Attestation (the MyMedicare.gov Link was moved to Section 17.7) to add information on CMS recent enhancements to the WCMSAP (the Portal) which now allows users to upload transactions (including annual attestations).  Additionally, professional administrators now will have the capability to upload and view information on the accounts they are administering.  An earlier NuQuest blog (https://mynuquest.com/cases-points-blog/workers-compensation-medicare-set-aside-electronic-attestation-enhancement/) detailed the release of these new functions and referenced the two webinars that CMS is hosting on these topics.

 Consent to Release Note

As noted in Section 10.2 of the Guide, effective April 1, 2020, Consent to Release notes are required to include language evidencing the claimant understands the intent, submission process and associated administration of the WCMSA.  This section of the Consent form must at least contain the claimant’s initials to indicate their validation.  Sample templates are also provided with instructions on completion of the form in Figure 10-1, 10-2 and Appendix 6.  The new language includes the following:

Further, I have had the Workers’ Compensation Medicare Set-Aside Arrangement need and process explained to me, and I approve of the contents of the submission.

 Beneficiary Initials: XX

The additional language puts an affirmative obligation on the claimant to not only agree to submission, but to understand and approve the process and the contents of the submission.  Based upon the foregoing, we may be seeing additional scrutiny by the claimant and counsel over CMS submission packets. 

Amended Review Extension

Amended Reviews will now be considered from 12 to 72 months from the date of CMS approval/conditional approval letter.  This expansion is a much needed change from the limit of 48 months contained in prior Guides.  Expanding the life of the Amended Review will allow parties to consider possible re-submission of WCMSAs for settlement in cases that were previously time barred by the 4-year restriction.  Significantly, this Section of the Guide also includes language that requests for changes to treatment will not be considered without supporting medical documentation.  The Guide also contain the link for details on electronic submissions of Re-Review and Amended Review requests. 

Hospital Fee Schedules

In Section 9.4.3, Medicare states it is now calculating hospital fees based upon the Diagnosis Related Groups (DRG) payments for the median Major Medical Center within the appropriate fee jurisdictions for the pricing ZIP code, unless otherwise defined by state law.

Previously, the reference guide stated that Medicare used a single fee based upon the DRG for a Major Medical Center and applied this to all locations within the jurisdiction. 

This change may require Medicare to choose a lower DRG payment in pricing a hospital service rather than using a blanket pricing for the entire state. Alternatively, Medicare may be required to choose a higher DRG payment pricing dependent upon the zip code used in the MSA analysis.

Other Changes

The new WCMSA life tables have been updated in Section 10.3 of the Guide.  The link for the Centers for Disease Control (CDC) Table can be found here https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_04-508.pdf

Addresses have been corrected or clarified for:

  • Reporting workers’ compensation cases:
    • Written reports of WC occurrences should be addressed to:
      • Medicare—Medicare, Secondary Payer
        Medicare Secondary Payer Claims Investigation Project
        P.O. Box 138897
        Oklahoma City, OK 73113-8897
    • For sending yearly WCSMA account attestations:
      • NGHP
        P.O. Box 138832
        Oklahoma City, OK 7311
    • For sending WCMSA proposals, final settlements, and re-review requests
      • WCMSA Proposal/Final Settlement
        P.O. Box 138899
        Oklahoma City, OK 73113-8899

“Death of a Claimant” information has been updated and standardized with the Self Administration toolkit for WCMSAs (Section 19.2)