On July 3, 2023, the Centers for Medicare & Medicaid Services (“CMS”) issued Version 1.4 of the Self-Administration Toolkit for Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) for WCMSAs approved by CMS. Version 1.3 was issued on October 10, 2019. The substantive revisions are detailed below. While limited, they are nonetheless important for those claimants self-administering WCMSAs.
The Table of Contents remains the same with no Sections added or deleted.
The first and most important change is in Section 1: Introduction addressing when Medicare will pay for costs related to a workers’ compensation claim. The Toolkit now provides “Medicare will pay those costs when your WCMSA is “appropriately exhausted” or “depleted.” “Appropriately” means you spent this money on what it is supposed to be used on, and “exhausted” means the money has all been spent.” In the Glossary (Section 14), “exhausted” and “depleted” have the same definition: “An account that has no money in it; it is used up.”
Section 4: Using the Account has two revisions. First, “to get a copy electronically” was removed following the link to the website providing the list of services covered and not covered by Medicare. Second, the last paragraph of the “What medical and prescription expenses can I pay for from this account?” has been changed to two sentences to avoid any misunderstanding regarding payments before and after the claimant is a Medicare beneficiary. The last paragraph now provides: “If you are not yet a Medicare beneficiary, pay all your WC-claim-related, Medicare-covered medical and prescription drug expenses from the account. When you become a Medicare beneficiary, continue to pay for WC claim-related expenses from the account until it is fully and appropriately exhausted.”
In Section 7: Keeping Records, the last sentence of the last paragraph now states Medicare may request “the register or other records” as proof that you are using the account correctly. The previous version did not identify specifically what documents CMS may request. While there is no definition of “register” in Section 7 or the Glossary (Section 14), presumably “register” refers to the “Transaction Record” mentioned earlier in Section 7. Section 13: Letters and Examples includes a sample transaction record.
In Section 8: Annual Attestation, the second paragraph changed the domain name to submit the yearly attestation to Medicare.gov from MyMedicare.gov. The Glossary definition of WCMSA Portal (WCMSAP) also includes this change.
Section 10: Inheritance removes the Medicare Regional Office (RO) from involvement with ensuring that all bills related to the WC claim have been paid following death of the beneficiary. Medicare’s Benefit Coordination & Recovery Center (BCRC) is now solely responsible for this task.
Section 12: Where to Get Help now lists one customer service line for assisting with the set up and administration of the WCSMA account rather than a link to a list of Medicare Regional Offices.
Proper self-administration of a WCMSA, whether approved by CMS or not, is critical to a seamless transition to Medicare coverage for work injury related treatment when the WCMSA funds are used up completely or until the next deposit is made. Staying informed of changes in CMS guidance regarding self-administration of WCMSA accounts is the best way for self-administrators to avoid running afoul of CMS requirements and risking loss of Medicare benefits for work injury related treatment.