Administering WCMSAs

Professional vs. Self Administration of WCMSAs

A WCMSA should be placed in an interest bearing account.  WCMSAs should also be administered by a competent administrator (the representative payee, a professional administrator, etc.).  When a claimant designates a representative payee, appointed guardian/conservator, or has otherwise been declared incompetent by a court; the settling parties must include that information in their Medicare set-aside arrangement proposal to CMS.(Ref: 10/15/04 Memo Q2)

In addition, the claimant may self-administer his or her own WCMSA, if permitted under State law.  Claimant should submit an annual self-attestation form when monies have been exhausted. (Ref:4/21/03 Memo Q8)

In professional administrative situations, the administrator of the set-aside arrangement must forward annual accounting summaries concerning the expenditures of the arrangement to the CMS Medicare contractor responsible for monitoring the individual's case. Additionally, the Medicare contractor is responsible for verifying that no payments from Medicare are made for medical expenses related to the injury or illness/disease until the WCMSA is exhausted. (Ref: 7/23/01 Memo Q3)

Administrative Fees/Expenses and/or Attorney Costs

(Ref: 5/7/04 Memo)

Administrative fees/expenses for administration of the WCMSA and/or attorney costs specifically associated with establishing the WCMSA cannot be charged to the set-aside arrangement. The CMS will no longer be evaluating the reasonableness of any of these costs because the payment of these costs must come from some other payment source that is completely separate from the WCMSA funds.

For example, if the settling parties submit a WCMSA proposal to CMS that claims that the claimant will need $50,000 worth of work-related medical expenses that would otherwise be reimbursable under Medicare and the settling parties claim that it will cost $10,000 in administrative and attorney fees in order to both administer and establish the Medicare set-aside arrangement proposal of $50,000, then CMS will only review the reasonableness of the $50,000 figure.

The CMS will not review whether or not the $10,000 in administrative and attorney fees are reasonable nor will CMS permit the settling parties to add that $10,000 amount to the $50,000 WCMSA amount. Therefore, if CMS approves that proposal for a $50,000 WCMSA, the settling parties $10,000 in administrative and attorney fees cannot be charged to/against the WCMSA of $50,000 because CMS considers those costs to be a separate issue for the settling parties to negotiate.

Treatment of Taxable Interest Income Earned on a WCMSA

(Ref: 7/11/05 Memo Q6)

If a claimant receives a Form 1099-INT for the interest income earned on his or her WCMSA account, the claimant or his/her administrator may withdraw an amount equal to the additional tax as a “cost that is directly related to the account” to cover the additional tax liability. This assumes that there is adequate documentation for the amount of incremental tax that the claimant must pay for the interest earned on this WCMSA.  Moreover, such documentation should be submitted along with the annual accounting.

Beneficiaries that Request Termination of a WCMSA Account

(Ref: 7/11/05 Memo Q10)

The administrator of the CMS-approved WCMSA should not release set-aside funds for any purpose other than the purpose for which the WCMSA was established without review from CMS. However, if the treating physician concludes that the claimant's medical condition has substantially improved, then the claimant (or the claimant's representative) may submit a new WCMSA proposal covering future expected medical expenses. Such proposals must justify at least a 25% reduction in the outstanding WCMSA funds. In addition, such proposal may not be submitted until at least five years after a previous CMS approval letter and should be accompanied by all supporting documentation not previously submitted with the original WCMSA proposal. The CMS decision on the new proposal is final and not subject to administrative appeal. The above proposals shall be submitted to:

CMS
c/o Coordination of Benefits Contractor
P.O. Box 33849
Detroit, MI 48232-5849
Attention: WCMSA Proposal

If CMS determines that a 25% or greater reduction is justified, CMS will issue a new approval letter. After CMS issues a new approval letter, any funds in the current WCMSA in excess of the newly calculated amount may be released to the claimant.

Effective August 25, 2008, the July 11, 2005 memorandum at Question and Answer 10, entitled “Beneficiaries that Request Termination of a WCMSA Account,” is rescinded.

Death of a Claimant Prior to Exhaustion of the Medicare Set-Aside Money

(Ref: 4/21/03 Memo Q21)

Once the Regional Office (RO) and the contractor responsible for monitoring the claimant's case verify that all of the claimant's claims have been paid, then any amount left over in the claimant's WCMSA may be disbursed pursuant to State law. This may involve holding the WCMSA open for some period after the date of death, as providers, physicians, and other suppliers are permitted to submit their initial bill to Medicare for a period ranging from 15-27 months after the date of service.

Transfer Mechanism for Items and Services Not Covered by Medicare

(Ref: 7/11/05 Memo Q15)

Should a WCMSA provide for items and services that are not covered by Medicare but later become covered, those funds should then be considered part of the set-aside and treated accordingly, i.e., used to pay for any services as they were designated in the non-Medicare portion of the set-aside included in the WC settlement. These funds do not have to be transferred to a separate WCMSA bank account or be included in the annual WCMSA accounting.