Sandy Simpson - Solutions for Workers' Compensation and Liability Settlements

08/Jul/2024

On July 2, 2024, the Centers for Medicare & Medicaid Services (CMS) created the Non-Group Health Plan (NGHP) Applicable Plan Appeals Reference Guide version 1.1.

To download the NGHP Applicable Plan Appeals Reference Guide Version 1.1 by clicking here.

Summary of NGHP Applicable Plan Appeals Reference Guide Version 1.1 and the Updates

Much like how the Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide focuses on the submission process for Workers’ Compensation MSA’s, this appeals reference guide seems more focused on appeals by employers’ WC plans as opposed to liability matters which would be handled by the beneficiary directly or their representatives, as it only references the Commercial Repayment Center (the “CRC”) as the entity to which to submit a first level Redetermination request. Because many of our readers inquire about Medicare lien appeals in the liability space, for liability cases, first level Redetermination requests may also be submitted via the Medicare Secondary Payer Recovery Portal (MSPRP) or the Benefits Coordination Recovery Center (“BCRC”) at P.O. Box 138832, P.O. Box 138832, Oklahoma City, OK 73113. The four step administrative appeals process prior to being able to appeal in federal District Court is similar for WC, No Fault, and liability cases but sometimes, the contractors hired by CMS to review the various stages may sometimes be different (and often are different in different parts of the country as well).

To clarify the process necessary to appeal based on the exhaustion of benefits, the list of required documentation has been updated (Section 4.1.1).

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

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Sandy Simpson

08/Jul/2024

On July 2, 2024, the Centers for Medicare & Medicaid Services (CMS) updated the MMSEA Section 111 NGHP User Guide version 7.6. It has been posted to the NGHP User Guide page on CMS.gov. The NGHP User Guide version 7.6 replaces Version 7.5 which was released on April 1, 2024. The updated MMSEA Section 111 NGHP User Guide version 7.6 has been posted to the NGHP User Guide page on CMS.gov.

MMSEA III – July 1, 2024 – NGHP User Guide Downloads 7.6

Chapter I: Introduction and Overview (PDF)

Updates: An expanded and specific definition has been to clarify the qualification of a cumulative injury for Section 111 NGHP reporting. (Chapter 2).

Chapter II: Registration Procedures (PDF)

Updates: There are no changes for this version.

Chapter III: Policy Guidance (PDF)

Updates: The submission of information related to Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) will be required for all records submitted with a TPOC date after April 4, 2025 (Section 6.5.1.1). As of January 1, 2024, the threshold for physical trauma-based liability insurance settlements will remain at $750. CMS will maintain the $750 threshold for no-fault insurance and workers’ compensation settlements, where the no-fault insurer or workers’ compensation entity does not otherwise have ongoing responsibility for medicals (Section 6.4).

Chapter IV: Technical Information (PDF)

Updates: Information on how to resolve TIN address errors was added (Sections 6.3.3 and 6.6.5).

Chapter V: Appendices (PDF)

Updates: An expanded and specific definition has been to clarify the qualification of a cumulative injury for Section 111 NGHP reporting (Section 3.2).

The language used to describe the date of incident and how a cumulative injury fits within that definition from CMS’ perspective with a caution note that CMS’ definition of cumulative injury is different from the insurance industry’s definition:

From Chapter 2, page 2-2, “CMS defines the Date of Incident (DOI) as follows:

The date of the accident (for an automobile or other accident);
The date of first exposure (for claims involving exposure, including; occupational disease, or any associated cumulative injury);
The date of first ingestion (for claims involving ingestion);
The date of the implant or date of first implant, if there are multiple implants (for claims involving implant(s); or
The earlier of the date that treatment for any manifestation of the cumulative injury began, when such treatment preceded formal diagnosis, or the first date that formal diagnosis was made by a medical practitioner (for claims involving cumulative injury).

Note: Cumulative injury refers to those categories of injuries that may persist or grow in severity, intensity, or pain but for which a formal diagnosis may not occur until a later date. Examples of cumulative injuries include, but are not limited to, carpal tunnel syndrome, or back pain that is not the result of an acute trauma. Exposure, ingestion, and inhalation injuries are not considered cumulative injuries for purposes of calculating DOI or any other reporting requirements. This CMS definition differs from the definition of that generally used by the insurance industry under specific circumstances. For the DOI used by the insurance and workers’ compensation industry, see Field 13 of the Claim Input File Detail Record in the NGHP User Guide Appendices, Chapter V.”

270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting NGHP Entities, Version 5.9 (PDF)

Updates: The end-of-line character has been clarified for files using HEW software (270/271 File Translation).

For Additional Information

Sandy Simpson

29/May/2024

When resolving a workers’ compensation case, the employer looks to see if the injured employee is a Medicare beneficiary and if there will be injury-related future medical care. If the answer to both questions is yes, then they must comply with the guidelines set forth by the Medicare Secondary Payer (MSP) statute.

With healthcare and Medicare costs on the rise and as the open claim moves through the settlement process, below are some settlement objectives to help keep costs down and stay MSP compliance.

WCMSA Arrangement: Centers for Medicaid and Medicare Services (CMS) recommends this method to ensure that Medicare’s interests are protected when settling a workers’ compensation claim that includes future medical expenses. Note that the WCMSA Arrangements are prepared based on today’s costs.
MSP Compliance: Employers are mandated to follow the MSP statute; it will ensure Medicare compliance when considering Medicare’s interest in the settlement. Failure to do so, you could face legal consequences from breaching the settlement agreement. CMS can also obtain reimbursement of injury related payments made from anyone involved in the settlement, including the worker, workplace, insurance companies and attorneys.
Cost Control: Striving to move an open claim toward settlement in the least expensive manner.
Future Medical Care: Employers can help prioritize the injured employee’s well-being for future medical care after settlement by hiring Medivest for Professional Administration services. Medivest Professional Administration ensures the Medicare Set-Aside (MSA) funds are spent according to the allowable guidelines whereby preserving the MSA dollars.

When to Request a WCMSA?

A WCMSA is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease that would normally be covered by Medicare. All parties involved in a workers’ compensation case have significant responsibilities under the MSP statute to protect Medicare’s interests when resolving cases that include future medical expenses.

Does the settlement contemplate future medical needs?
Is the injured employee eligible or receiving Medicare benefits?
Has the injured employee applied or re-applied for Social Security Disability Insurance (SSDI)?
Is the injured employee 62.5 years old?

Common WCMSA Cost Drivers

When a Medivest WCMSA Arrangement is ordered, a Cost Driver Analysis report will be included. A Cost Driver Analysis report identifies the various costs that are driving up the WCMSA amount, such as opioids, injections, and surgeries. Below are some common WCMSA cost drivers when a report is prepared.

Poly Pharmacy: The use of multiple drugs and lifetime pharmacy costs.
Implantable Devices: Devices such as spinal cord stimulators, intrathecal pain pumps which also includes replacement cost and mediation refills.
Surgeries and Replacement Costs: Non planned surgeries.

WCMSA Cost Mitigation Strategies

When carriers and employers optimize cost mitigation strategies, they can achieve an accurate and timely settlement. The following are examples of helpful strategies.

RX Drug Cost: Reducing prescription drug costs can be used as a pre-MSA strategy by weaning/tapering off some medications, choosing a generic substitution, or using a physician letter (to address changes in medications.
Cost Drivers: Identify treatments or medications that are driving up the total amount of the WCMSA. Review and possibly implement the recommendations provided in the Cost Driver Analyst report to help reduce the WCMSA amount.
Rated Age: If medical records show evidence of a reduced life expectancy, then a Rated Age may be obtained and used when calculating the WCMSA. CMS approves Rated Ages when used in WCMSAs which reduces the life expectancy thus reducing the overall amount of the WCMSA figure.
Structured Settlement: Fund the MSA with a structured settlement instead of a lump sum. CMS approves MSAs to be structured and Medicare will cover expenses for the injured employee during temporary exhaustion if the MSA allocation was approved by CMS. Also, utilizing a structure can provide significant cost savings for the funding party compared to a lump sum payment.

Ready To Order Your WCMSA?

Begin by completing an online referral by clicking here and upload the following documents.

Most recent 2 years of medical records
Most recent 2 years of Rx invoice
Most recent 2 years of indemnity payouts (Work Comp cases only)

About Medivest

Medivest has worked with carriers and employers for over 2 decades to understand their unique needs and responsibilities to their injured workers. Every WCMSA Arrangement is produced by a highly trained nurse that possesses a wealth of knowledge and experience in the preparation of these reports. We understand that creating and maintaining a WCMSA can be complex, let Medivest prepare your next report. Our nurses and staff hold industry certifications or designations including CMSP, CMSP-F, CPC, MSCC, CSSC, JD, RN, and BSN.

Sandy Simpson

22/May/2024

The Centers for Medicare & Medicaid Services (CMS) has released the Self-Administration Toolkit for WCMSAs version 1.5 on May 15, 2024. The Toolkit replaces Version 1.4 which was released on July 3, 2023.

To download the new Self-Administration Toolkit for WCMSA Version 1.5 click here.

Self-Administration With Additional Help

For injured parties who are considering self-administration, but who also want additional consultation on the process, Medivest provides a Self-Administration Kit. With purchase of the Medivest Medicare Set-Aside Self-Administration Kit, the injured person will receive a one-hour consultation on the proper administration of a Medicare Set-Aside account, covering topics including:

- Where to deposit and hold Medicare Set-aside funds
- Which expenses are allowed to be paid from a Medicare Set-Aside account
- What rates must be used to negotiate and pay for expenses
- How to annually report the Medicare Set-aside to the CMS
- What to do if the MSA funds exhaust temporarily or permanently
- How to discuss a Medicare set-aside with a medical provider
- What are the tax implications of interest earned on Medicare Set-Aside funds

For Additional Information

Medivest will continue to monitor changes occurring at CMS and will keep its readers up to date when such changes are announced. For questions about self administration, professional administration or anything else regarding rules and recommendations from CMS, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

Sandy Simpson

02/Apr/2024

The Centers for Medicare & Medicaid Services (CMS) released a revised Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (“Reference Guide”) Version 4.0 on April 1, 2024. This Reference Guide replaces Version 3.9 which was released on May 15, 2023. There are a few notable changes when comparing the two Reference Guides.

Changes in This Version 4.0 of this Guide Include the Following Changes:

Instruction specific to beneficiaries has been added to encourage them to use their Medicare.gov access to the portal for the most efficient method of submitting attestations (Sections 11.1.1 and 17.5). This user-friendly mechanism which allows CMS to gain potentially more MSA spending information than it has received via traditional mailing, may lead to CMS denying more future medical claims or potentially considering whether recovery of future medical payments that slipped through the cracks is viable.
The CDC Life Table link was updated (10.3) – available to view here.

To download the new WCMSA Reference Guide v4.0 click here. This guide reflects information compiled from all WCMSA Regional Office (RO) Memoranda issued by CMS, from information provided on the CMS website, from information provided by the Workers Compensation Review Contractor (WCRC), and from the CMS WCMSA Operating Rules. The intent of this reference guide is to consolidate and supplant all historical memoranda in a single point of reference. Please discontinue the reference of prior documents.

For Additional Information

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Sandy Simpson

31/Jan/2024

The January 18th, 2024 webinar hosted by Centers for Medicare & Medicaid Services (CMS) entitled Medicare Secondary Payer and Certain Civil Money Penalties (Non-Group Health Plan) is now available in the Download section of the What’s New page on CMS.gov. The webinar can be viewed in its entirety, or you may download the materials covered in PDF format by clicking here.

Medivest will continue to monitor news and updates from CMS and will keep its readers up to date when important announcements are made. For questions regarding the information presented in this webinar or any other recent CMS updates, please reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

Sandy Simpson

22/Jan/2024

On January 10, 2024, the U.S. Department of Labor published a final rule, revising its guidance to employers and workers to help determine if a worker qualifies as an employee or an independent contractor (IC) under the Fair Labor Standards Act (FLSA). The final ruling explains that the economic reality test is comprised of six-factors that are a guide to conduct the totality-of-the circumstances analysis to determine economic dependence. The new ruling takes effect March 11, 2024. To view the final ruling, click here.

Misclassification Issues

Employers need to distinguish between employees and independent contractors when considering eligibility for workers’ compensation. Correctly distinguishing between employees and independent contractors is crucial for legal compliance, cost management, liability avoidance, and ensuring workers receive the appropriate benefits and protections. Misclassification can have significant financial and legal consequences for employers.

What is the Economic Realities Test?

The US Department of Labor uses an economic realities test to help employers comply with the law, reduce the risk of employee misclassification, and to help determine if a worker is classified as an independent contractor or as an employee. This test consists of six-factors that are all weighed against each other. All factors should be considered. No single factor determines a worker’s status. No one factor or combination of factors is more important than the other factors. This test considers the totality of the circumstances of the working relationship. Below are the six (6) factors.

Opportunity for profit or loss depending on managerial skill,
Investments by the worker and the employer,
Permanence of the work relationship,
Nature and degree of control,
Whether the work performed is integral to the employer’s business
Skill and initiative

About Medivest

Since 1996 Medivest has been helping our clients navigate the complexities of MSP compliance. We offer settlement solutions for workers’ compensation and liability settlements. Count on Medivest to help keep you up to date with the constant updates regarding Federal Register rulings, Medicare Secondary Payer legislation and changes related to CMS’s enforcement of the Medicare Secondary Payer. For questions, feel free to reach out to a Medivest representative in your area by clicking here or call us direct at 877.725.2467.

Sandy Simpson

08/Jan/2024

It is getting close to that time of year when mailboxes begin to receive W-2 statements and 1099-INT statements. If an injured individual has either a Self-Administered Medicare Set-Aside (MSA) account or a Professionally-Administered MSA account, the individual will be sent a 1099-INT by January 31^st and a copy will be filed with the IRS. The 1099-INT shows interest earned in the account during the previous tax year.

Liability and Workers Compensations cases should follow the Workers Compensation Medicare Set-Aside (WCMSA)Reference Guide, until CMS publishes a Liability Medicare Set-Aside (LMSA) Reference Guide. Until then, the WCMSA Reference Guide should be considered a single point of reference for Liability and Workers Compensation cases. To download the WCMSA Reference Guide Version 3.8, Dated November 14, 2022, click here.

What the WCMSA Reference Guide states:

MSA funds must be placed in an interest-bearing account that is separate from the individual’s personal savings and checking accounts.
The interest must be deposited into the MSA account to be used for MSA-covered expenses.
You can use the MSA account to pay for the income tax on the interest income.

For further clarification regarding how the individual can pay for the taxes from the interest incomed earned in their account, refer to the CMS Memo Dated July 11, 2005, Subject: Medicare Secondary Payer (MPS) – Workers’ Compensation (WC) Additional Frequency Asked Questions.

“Q6. Treatment of Taxable Interest Income Earned on a WCMSA – If I receive a Form 1099-INT for the interest income earned on my WCMSA account, may I charge the income tax on that amount against the WCMSA?

A6. Assuming that there is adequate documentation for the amount of incremental tax that the claimant must pay for the interest earned on this set-aside 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. Such documentation should be submitted along with the annual accounting.”

How Medivest Handles the 1099-INT:

Medivest will advise the Member to prepare his/her tax return two ways to determine the increased income tax burden, if any:

Include the MSA interest income in the income tax return
Exclude the MSA interest income in the income tax return

In other words, if the Member must pay the IRS an increased income tax amount as a result of the interest earned from their MSA account, the additional income tax burden can be paid from the MSA account. This is considered a cost associated with having the MSA account and CMS allows this expense to be paid from the MSA account. Once a year, Medivest will send CMS an attestation for every applicable professionally-administered MSA account. Any MSA reimbursement of the additional income tax burden will be included in this attestation.

Answers to Common Questions

Question 1. If I am taxed on the earned interest, why can’t I have it?

Answer 1. CMS’ guidelines state that Medicare Set-Aside funds place must be placed into an interest-bearing account and are to be used for covered medical expenses.

Question 2. Why do I have to report the earned interest to the IRS?

Answer 2. Per IRS guidelines, all interest income is taxable, unless specifically excluded.

Question 3. Isn’t my injury settlement tax-exempt?

Answer 3. Any compensation you receive from a settlement because of physical injuries or sickness is not taxable. However, the interest earned after the settlement occurs is taxable.

Best Practices

Medivest’s highly trained representatives can help you figure out if Medicare may have an interest in your settlement. We assist all settling parties to navigate the MSP complexities and provide you with cost-saving strategies for your settlement. For questions about your account or setting up a new professional administration account please contact us here.

Sandy Simpson

20/Dec/2023

You have settled your injury case and have decided to self-administer your Medicare set-aside (MSA) arrangement. Whether you are just beginning to embark on this journey or if you have been self-administering your account for a while and need a refresher, here are a few tips you should know. These tips can help you navigate through this complicated process. They will ensure that you won’t jeopardize your Medicare benefits, help you preserve your MSA funds so they will be there when you need them the most, and will help you prepare to administer your MSA throughout 2024 and beyond.

Helpful Self-Administration Tips:

Set Up your MSA Correctly

Know how your Medicare Set-Aside account will be funded. There are two ways to fund MSA account either with a lump-sum payment or a structured annuity. If your settlement says that it will be funded as a lump sum, one check will be issued. Or, if your settlement says that it will be funded with a structured annuity, then an initial deposit is made to establish the account, followed by annual deposits.
Open a separate bank account to deposit your MSA funds. Do not co-mingle your MSA funds with your personal funds.
Deposit your MSA funds into an interest-bearing bank account, insured by FDIC.
It is recommended to find a bank that does not charge fees when you have a low balance and preferably to find an account that you could write checks on.

Learn the Process and Develop Good Habits Now

Keep your settlement paperwork in a safe place.
Know your date of settlement. Any expense that is injury related, Medicare covered, and has occurred after the date of settlement can be paid out of your Self-Administered Medicare Set-Aside account.
Only use the MSA funds from your account to pay for Medicare covered medical treatment and prescription costs related to your injury, even if you are not yet enrolled in Medicare.
Keep accurate records of the expenses you’ve paid out of your account. You will not submit these records annually, but Medicare may request these records as proof that you are using the account correctly.
- Transaction date
- Check number (if any, or transaction number if present)
- “Payable to” or health care provider name
- Date of service
- Description (procedure, service, or item received; deposit; interest; other allowable expense)
- Amount paid
- Any deposit amount
- Account balance
- Keep itemized receipts
- Banks statements
- Tax records
You will need to send an annual attestation form every year to Medicare, no later than 30 days after the anniversary date of your Workers Compensation settlement regarding funds remaining in the account after expenses have been paid.

Know What Expenses Your MSA Covers

MSA account can be used to pay for the following:
- Cost of copying documents
- Mailing fees/postage
- Any banking fees related to the account
- Income tax on interest income from the account

You may not use the MSA account to pay for:

- Fees for trustees, custodians, or other professionals hired to help administer the account
- Expenses for administration of the MSA (other than those listed above)
- Attorney costs for establishing the MSA
- Medicare premiums, co-payments and deductibles

To learn what expenses are considered Medicare covered. Get the free annual publication called Medicare & You from your Social Security office, or at: https://www.medicare.gov/medicare-and-you/medicare-and-you.html

What to Do When Your MSA is Exhausted or Depleted

If you are a Medicare beneficiary and your funds have been depleted, you can forward your bills to Medicare for payment as long as the expense is Medicare covered and injury related.
If you are not Medicare covered and your funds have been depleted, you will need to coordinate benefits with your other health insurance providers or pay out of pocket.
When your account is permanently exhausted or depleted, which means there is no money left in the account and there will be no future deposits, you will need to submit within 60 days of the date your account is depleted a final attestation letter stating the account is ‘completely exhausted’.
Notify Medicare’s Benefits Coordination & Recovery Center (BCRC) if death has occurred before the WCMSA is permanently exhausted.
If you lose your Medicare entitlement, you are not entitled to release the MSA funds.

What Happens it Self-Administering is Too Difficult?

If learning how to self-administer your MSA on your own is too difficult to navigate, contact Medivest to learn more about our Self-Administration Kit with assistance. Or, if you’re interested in a more hands-off solution, Medivest Professional Administration Services can remove potential risks and the cumbersome tasks associated with administrating your Medicare Set-Aside funds, and in most cases can even stretch the lifespan of a MSA. Please call us at 877.725.2467 or reach out to us here.

Sandy Simpson

25/Jul/2023

On July 19, 2023, the Centers for Medicare & Medicaid Services (CMS) released their list of the Top 10 Section 111 Non-Group Health Plan Reporting Errors between January 1 – June 30, 2023. The chart with the list of errors and their rank can be viewed below. A downloadable PDF of this chart cane be found at the CMS website here.

Medivest will continue to monitor news and updates from CMS, and will keep its readers up to date when important announcements are made. For questions about this chart or any other recent updates, feel free to reach out to the Medivest representative in your area by clicking here or call us direct at 877.725.2467.

Older Posts

Summary of NGHP Applicable Plan Appeals Reference Guide Version 1.1 and the Updates

For Additional Information

MMSEA III – July 1, 2024 – NGHP User Guide Downloads 7.6

For Additional Information

When to Request a WCMSA?

Common WCMSA Cost Drivers

WCMSA Cost Mitigation Strategies

Ready To Order Your WCMSA?

About Medivest

Self-Administration With Additional Help

For Additional Information

Changes in This Version 4.0 of this Guide Include the Following Changes:

For Additional Information

Misclassification Issues

What is the Economic Realities Test?

About Medivest

What the WCMSA Reference Guide states:

MSA funds must be placed in an interest-bearing account that is separate from the individual’s personal savings and checking accounts.

The interest must be deposited into the MSA account to be used for MSA-covered expenses.

You can use the MSA account to pay for the income tax on the interest income.

For further clarification regarding how the individual can pay for the taxes from the interest incomed earned in their account, refer to the CMS Memo Dated July 11, 2005, Subject: Medicare Secondary Payer (MPS) – Workers’ Compensation (WC) Additional Frequency Asked Questions.

“Q6. Treatment of Taxable Interest Income Earned on a WCMSA – If I receive a Form 1099-INT for the interest income earned on my WCMSA account, may I charge the income tax on that amount against the WCMSA?

How Medivest Handles the 1099-INT:

Medivest will advise the Member to prepare his/her tax return two ways to determine the increased income tax burden, if any:

Include the MSA interest income in the income tax return

Exclude the MSA interest income in the income tax return

Answers to Common Questions

Question 1. If I am taxed on the earned interest, why can’t I have it?

Answer 1. CMS’ guidelines state that Medicare Set-Aside funds place must be placed into an interest-bearing account and are to be used for covered medical expenses.

Question 2. Why do I have to report the earned interest to the IRS?

Answer 2. Per IRS guidelines, all interest income is taxable, unless specifically excluded.

Question 3. Isn’t my injury settlement tax-exempt?

Answer 3. Any compensation you receive from a settlement because of physical injuries or sickness is not taxable. However, the interest earned after the settlement occurs is taxable.

Best Practices

Helpful Self-Administration Tips:

Set Up your MSA Correctly

Learn the Process and Develop Good Habits Now

Know What Expenses Your MSA Covers

What to Do When Your MSA is Exhausted or Depleted

What Happens it Self-Administering is Too Difficult?

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