CMS Updates WCMSA Reference Guide

On January 5, 2015, the Centers for Medicare and Medicaid Services (CMS) updated its Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide to version 2.3. The initial version of this guide was published on March 1, 2013, which started a welcomed initiative to publish a resource to help users understand the process used by CMS for approving WCMSAs.

Version 2.3 of this guide listed the following changes in Section 1.1:

  • Updated some language to clarify and to correspond with recent changes to letters.
    • Corrected a reference from 42 CFR 411.46 to Section 1862(b)2) of the Social Security Act.
    • Clarified reference to costs related to the workers’ compensation claim, rather than the compensable injury.
    • Clarified reference to future medical items and services as “Medicare covered and otherwise reimbursable”.
    • Clarified that CMS approves the WCMSA amount, not the WCMSA upon submission of a request.
    • Correspondingly, clarified language referring to submission of a proposed WCMSA amount, rather than a WCMSA proposal.
    • Restated the comparison of fee-schedule vs. full-and-actual-costs pricing as the basis of pricing the proposed amount, rather than the basis of payment from an approved WCMSA account.
    • Clarified attestation vs. accounting wording.
    • Clarified procedural results when Medicare is not provided with information in response to a development request.
    • Removed the word “form” from references to documents that are not forms.
  • Added language to address schedule change for hydrocodone compounds from schedule III to schedule II. See Section
  • Changed deadline for responding to development requests for submission through the WCMSA Portal to 20 from the previous 10 days. See Sections 9.4.1 and 9.5.

The inclusion of language to address hydrocodone compounds changing from schedule III to schedule II corresponds to a previous announcement CMS published on November 17, 2014 titled, Notice of Hydrocodone Combination Product Coverage Changes in Medicare Part D Effective for WCMSA Proposals Submitted on or after January 1, 2015. It is also important to note the users now have 20 days to respond to development requests through the WCMSA Portal instead of the previous 10 days.

We applaud CMS for its continuing efforts to provide and update this valuable reference guide, and we will keep you informed as changes are made.


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