Submissions of WCMSAs

The Submission Process

All WCMSA proposals submitted for CMS review must be sent to:

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

EFFECTIVE AUGUST 27, 2007

The WCMSA proposals will then be recorded in a national, centralized database, and electronically forwarded to CMS' Review Contractor. 

Electronic Submission

The most efficient method for submission of a WCMSA proposal is on a CD-ROM. The Coordination of Benefits (COB) Contractor's enhanced processing system has the ability to directly import the documentation on a CD-ROM; managing the documentation more effectively.

Upon receipt, the documentation is electronically transmitted into the COB Contractor's processing system and, provided all required information is included, it is then sent to a centralized database for review.

CD-Rom Submission

• Include the items listed in the Workers' Compensation (WC) Medicare Set-aside Proposal Requirement Checklist. Please see the link for the WC Submission Checklist under Downloads.
• Place files directly on the CD so that they can be viewed immediately once the CD is opened.  Do not save the file in a folder.
• Submit files in PDF format.  The file extension must be .pdf.
• Categorize the files based on the following codes and use the associated code as the prefix in the naming convention:

05 - Submitter Letter or Other Summary Documentation
10 - Consent Form
15 - Rated Age Information or Life Expectancy
20 - Life Care Plan
25 - Settlement Agreement or Proposed or Court Order
30 - Set-Aside Administrator or Copy of Agreement
35 - Medical Records
40 - Payment History
45 - Future Treatment Plan
50 - Supplemental or Additional Information

For example, a CD might contain the following files:

10ConsentForm1.pdf

10ConsentForm2.pdf

20LifeCarePlan.pdf

35MedicareRecordsDoc.pdf

Please note that the WC Submission Checklist requires that all information provided on a CD-ROM be in PDF format. Medical records must be submitted in a logical order.

Settlement of Workers' Compensation (WC) Medical Expenses Prior to Submission to CMS

(Ref: 7/11/05 Memo Q5)

The parties can proceed with the settlement of the medical expenses portion of a WC claim before CMS actually reviews the proposed WCMSA and determines an amount that adequately protects Medicare's interests.  However, any statement in the settlement of the amount needed to fund the WCMSA is not binding upon CMS unless/until the parties provide CMS with documentation that the WCMSA has actually been funded for the full amount as specified by CMS that adequately protects Medicare's interests as a result of its review.

If CMS does not subsequently provide approval of the funded WCMSA amount as specified in the settlement and proof is not provided to CMS that the CMS-approved amount has been fully funded, CMS may deny payment for services related to the WC claim up to the full amount of the settlement. Only the approval of the WCMSA by CMS and the submission of proof that the WCMSA was funded with the approved amount, would limit the denial of related claims to the amount in the WCMSA. This shall be demonstrated by submitting a copy of the final, signed settlement documents indicating the WCMSA is the same amount as that recommended by CMS.

As a reminder, the claimant may be at risk if the WCMSA is funded for less than the amount that CMS determines to be adequate to protect Medicare's interests.

Helpful Tools

Who to Contact

Once you have submitted a WCMSA proposal, you will receive an acknowledgement letter. If you do not receive an acknowledgement letter, please contact the Coordination of Benefits (COB) Contractor. Customer Service Representatives are available to provide you with quality service Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays. The COB Contractor's toll free number is 1 (800) 999-1118 or TTY/TDD: 1 (800) 318-8782 for the hearing and speech impaired.

Downloads

Links are provided below which include materials to assist submitters in the WCMSA proposal process. You may download the WC Submission Checklist, which is a complete list of the information necessary for submissions to CMS. In addition, you may download the WC Sample Submission. Please note that the sample submission is merely intended to aid submitters in organizing the information that is typically sent to CMS with their WCMSA proposals. Each state may have unique forms. The sample submission is not intended to make or change policy.

Additional downloads which include, Determining if a WCMSA is Reasonable and Life Care Plans or Similar Evaluations, have been provided below.

Submission Tips

The Parties Should Indicate How Much of the Settlement is for Past v. Future Medical Expenses

(Ref: 4/21/03 Memo Q3)

A settlement that does not specifically account for past versus future medical expenses will be considered to be entirely for future medical expenses once Medicare has recovered any conditional payments it made. This means that Medicare will not pay for medical expenses that are otherwise reimbursable under Medicare and are related to the WC case, until the entire settlement is exhausted.

Example: A beneficiary is paid $50,000 by a WC carrier, and the parties to the settlement do not specify what the $50,000 is intended to pay for. If there is no CMS approved Medicare set-aside arrangement, Medicare will consider any amount remaining after recovery of its conditional payments as compensation for future medical expenses.      

Additionally, please note that any allocations made for lost wages, pre-settlement medical expenses, future medical expenses, or any other settlement designations that do not consider Medicare's interests, will not be approved by Medicare.

Example: The parties to a settlement may attempt to maximize the amount of disability/lost wages paid under WC by releasing the WC carrier from liability for medical expenses. If the facts show that this particular condition is work-related and requires continued treatment, Medicare will not pay for medical services related to the WC injury/illness until the entire settlement has been used to pay for those services.

Use of WC Fee Schedule vs. Actual Charges for WC Medicare Set-aside Arrangement

(Ref:  10/15/04 Memo Q1)

The CMS uses either the WC fee schedule (for states that have such schedules) or the full actual charges for its review of a proposed WCMSA based upon whichever methodology is used by the individual/entity submitting the proposal. The administrator of the WCMSA (both professional administrators and self administrators) should make payments from the WCMSA on the same basis. That is, if the proposal was submitted and approved based upon full actual charges, the administrator should make payment from the WCMSA based upon full actual charges; if the proposal was submitted and approved based upon WC fee schedule amounts, the administrator should make payment from the WCMSA based upon WC fee schedule amounts.

The CMS reviews WCMSAs on a case by-case basis in order to determine whether Medicare has an obligation for services provided after the settlement that originally were the responsibility of WC.  Accordingly, in reviewing a WCMSA, CMS must know whether the arrangement is based upon WC fee schedule amounts or full actual charge amounts. (Ref: 7/23/01 Memo Q5 Note).

Medicare Set- Aside Arrangements should be Funded Based on the Life Expectancy of the Individual 

(Ref:  7/23/01 Memo Q6)

In order to protect the Medicare Trust Fund, a WCMSA should be funded based on the expected life expectancy of the claimant unless State law specifically limits the length of time that WC covers work related conditions. If an estimate of the claimant's estimated longevity was not submitted, one must be obtained.

Inflation Adjustment/Discount for Present Value/Change in Policy

(Ref:  10/15/04 Memo Q4)

WCMSAs do not need to be indexed for inflation and may not be discounted to present-day value.

For additional information with regard to the WCMSA submission and review process, please click on our other WCMSA web pages.