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| Milestone Consulting, LLC
CMS (2)


CMS announced on its website yesterday that updates have been made to Version 2.2 of the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide. Updates include:

  • 4.1.4– Hearing on the Merits of the Case: Section added to reflect the April 22, 2003 WCMSA RO Memorandum (Question #5)
  • 9.4.4– Medical Review- Step 8: Clarification of submission requirements for medical records and payment records.
  • 10.8- Section 40– Payment History: Updated requirements for denied conditions.
  •– Pharmacy Guidelines and Conditions: Removed reference to Drug Tables for physician-dispensed drugs;Consolidation of Drug Tapering and Drug Weaning sections.
  • 10.5.2– Use of WC Fee Schedule vs. Actual Charges for WCMSA: Wisconsin added to list of states with no Workers’ Compensation fee schedule.
  • 10.7- Section 35– Medical Records: Removed two year requirement of medical records for unrelated to work injury; Clarified treating physician statements requirements.
  • 10.8- Section 40– Payment History- Requirements for denied conditions.

Of particular interest is the addition of Section 4.1.4, which was originally detailed in an April 22, 2003 Workers’ Compensation FAQ released by CMS. This section states,

When a state WC judge approves a WC settlement after a hearing on the merits, Medicare generally will accept the terms of the settlement, unless the settlement does not adequately address Medicare’s interests. If Medicare’s interests were not reasonably considered, Medicare will refuse to pay for the services related to the WC injury (and otherwise reimbursable by Medicare) until such expenses have exhausted the dollar amount of the entire WC settlement. Medicare also will assert a recovery claim if appropriate.

  • If a court or other adjudicator of the merits (e.g., a state WC board or commission) specifically designates funds to a portion of a settlement that is not related to medical services (e.g., lost wages), then Medicare will accept that designation.

This is a significant addition to the Reference Guide, as it provides the claimant with reassurance that in the context of a Workers’ Compensation settlement, a judicial allocation of medicals AND non-medicals will be acceptable to CMS.

The additions/clarification to Section 10.7 are also important to note. The previous version of the Reference Guide (v. 2.1), required the submission of medical records for the last two years of non-injury related treatment, along with a written explanation of the treatment; the new version of the Guide no longer requires that. A clarification was made to what the treating physician must provide, though—if a claimant has not been treated for any reason within the past two calendar years, the treating physician(s) must state when the last two years of treatment occurred AND must state in writing the specific condition/injury the claimant was last treated for, along with any related therapy.


These updates to the Reference Guide are encouraging; they offer another step towards cleaning up the MSA process (at least for Workers’ Comp settlements) so that the claimants can rest assured that the appropriate steps have been taken to protect their settlements and comply with Medicare requirements.


The full WCMSA Reference Guide can be viewed here.



Related Posts:

CMS Releases Update for MSP Reporting Threshold

CMS Releases Memo With Major Implications for Liability Settlements

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