CMS Releases WCMSA Reference Guide and Self-Administration Tool-Kit

April 9, 2025 / 4 min read

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The Centers for Medicare and Medicaid Services (CMS) has released an updated Workers' Compensation Medicare Set-Aside (WCMSA) Reference Guide (Version 4.3, April 7, 2025) and a new WCMSA Self-Administration Tool Kit (Version 1.7, April 4, 2025).

The below provides a general overview and highlights of these updates as follows:

WCMSA Reference Guide (Version 4.3)

CMS’s stated updates are (1) the addition of a sample Notice of Settlement Received letter to support the Medicare set-aside reporting requirements, (2) updated language indicating the one-year waiting period for amended reviews has been removed, and (3) update to the guide clarifying CMS’s policies surrounding change of submitter.[1]

The authors outline a summary of each of these changes below:

Update #1: Sample Notice of Settlement Received Letter

CMS notes that a sample “Notice of Settlement Received letter” was added to Appendix 5 of Version 4.3 in support of the new TPOC/WCMSA reporting requirements.[2] This sample letter, addressed to the MSA submitter, indicates that CMS has received notification of settlement that includes a WCMSA amount and that the information will be used to assist CMS in making appropriate determinations concerning coordination of benefits.[3]

CMS’s sample letter further outlines that CMS expects the WCMSA funds to be used to pay for medical and pharmacy care related to the workers’ compensation injury that would normally be paid by Medicare, that WCMSA funds cannot be used to purchase Medicare supplement or Medigap policies, and includes information regarding the submission of annual attestations.[4] CMS further indicates that once the funds in a WCMSA account have been properly spent on Medicare covered items and services related to the workers’ compensation claim, and Medicare has been given proof that the account has been properly exhausted, Medicare will begin paying for Medicare-covered items and services related to the workers’ compensation claim.[5]

Update #2: Removal of One Year Waiting Period for Amended Review

As part of the updates to version 4.3, CMS has removed the one year waiting period for the submission of an Amended Review of a prior WCMSA submission.[6] More detail surrounding this change can be found in our recent article, however to briefly summarize, the Amended Review process allows parties a one-time request to submit new medical documentation to adjust a prior WCMSA approval for cases meeting the Amended Review requirements.[7]

With the removal of the one year waiting period, CMS now requires the following criteria be met for an Amended Review submission: (a) CMS has issued a conditional approval/approved amount; (b) The case has not yet settled as of the date of the request for re-review; and (c) Projected care has changed so much that the submitter’s new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’s previously approved amount.[8] With this change, workers’ compensation insurers should consider reviewing open claims with a WCMSA approval to determine if the Amended Review process could assist in lowering CMS’s previously approved WCMSA amount to optimize potential claim settlement.

Update #3: Clarifying CMS’s Process Regarding Change of Submitter

Version 4.3 also includes several updates to clarify CMS’s policies surrounding change of submitter.[9] Briefly, if there is a change in the party submitting a WCMSA to CMS, CMS’s policy is to require a written release from services by the current submitter and a new signed Consent to Release form authorizing the new submitter.[10] As part of this update, CMS updated Section 16.3 to clarify that “a change of submitter alone if not sufficient grounds to require an amended review.”[11] In Section 19.4, CMS further updated the guide to note that submitter changes do not constitute a reason for an amended review.[12]

Self-Administration Tool-Kit (Version 1.7)

From the authors’ review, CMS appears to have revised a significant portion of their Self-Administration Tool Kit and revamped several sections by adding additional information and guidance for the benefit of individuals who settle their workers’ compensation claims with a WCMSA. Individuals familiar with the prior version of the toolkit will note that this most recent version provides more information in the introduction along with background information and an explanation of what an WCMSA is, and how it is used. It also attempts to clarify the use of terms commonly used in workers’ compensation claims and the administration of WCMSA funds. Overall, the substance of the toolkit remains largely the same from prior iterations.

Questions?

Please contact the authors if you have any questions regarding these updates or how Verisk can help you improve your WCMSA practices, including compliance with CMS’s new TPOC/WCMSA reporting requirements.

[1] CMS’s WCMSA Reference Guide (Version 4.3, April 7, 2025), Section 1.1 (Changes in this Version of the Guide).

[2] Id.

[3] Id, Appendix 5.

[4] Id.

[5] Id.

[6] Id, Section 1.1 (Changes in this Version of the Guide).

[7] Id, Section 16.3 (Amended Review).

[8] Id.

[9] Id, Section 1.1 (Changes in this Version of the Guide).

[10] Id, Section 19.4 (Change of Submitter).

[11] Id, Section 16.3 (Amended Review).

[12] Id, Section 19.4 (Change of Submitter).

CMS Releases Updated WCMSA Reference Guide and Self-Administration Tool-Kit

Questions?