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The Medivest Blog

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06/Jun/2025

Beginning June 14, 2025, the Centers for Medicare & Medicaid Services (CMS) will begin using the CDC’s 2022 “Table 1: Life Table for the total population: United States” for calculating life expectancy in Workers’ Compensation Medicare Set-Aside (WCMSA) arrangements.

This updated Life Table plays a crucial role in determining how long a Medicare Set-Aside account should fund a beneficiary’s future medical costs stemming from workers’ compensation or liability claims. The life expectancy figure from the CDC’s table directly impacts the allocation timeline for projected medical expenses. Additionally, CMS typically references this data in its WCMSA Reference Guide, including Appendix 2, which specifies the Life Table year in use.

You can view the 2022 Life Tables on the CDC’s official site here.

For Additional Information

As always, Medivest remains committed to assisting our clients with the creation and administration of WCMSAs. Medivest will continue to monitor changes at CMS and keep our readers updated when new changes are announced. For questions, feel free to reach out to the Medivest representative in your area by clicking here or call us at 877.725.2467.


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03/Jun/2025

CMS will be hosting an Introduction to WCMSAs Webinar. The intent of this webinar is to go over the basics of WCMSAs including purpose, submission guidelines and administration as well as to offer some WCMSA best practices. The presentation will be followed by a question-and-answer session. As this Webinar is intended to provide a general overview of the WCMSA process, questions regarding specific cases are not appropriate for this setting. Those involved in the submission and administration of WCMSAs, including attorneys and Medicare beneficiaries, are encouraged to attend.


 

Date: June 17, 2025
Time: 2:00 PM ET

Webinar Link:  https://cms.zoomgov.com/j/1605891582?pwd=7NeMcu0ezDDwYCCRiezZMY2MLiXY0d.1
Passcode: 922100

Or to connect via phone:

Conference Dial In: 1-833-568-8864
Conference Passcode: 160 589 1582

Important Note: This is a public webinar, and there is no pre-registration. The link above will not be active until the day of the webinar.


 

Additional information about the most recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients or your company, please contact Medivest or call us at 877.725.2467.

 


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Effective July 1, 2009, the Medicare & Medicaid SCHIP Extension Act (MMSEA) requires that “applicable plans” must first determine whether an injured party (including an individual whose claim is unresolved) is entitled to Medicare benefits. The primary payer must then report the “required information,” once the case is resolved, to the Secretary of the Department of Health and Human Services (Secretary of HHS) in the “form, manner, and frequency” the Secretary prescribes (CMS is a regulatory body under HHS). If this information is not provided to Medicare in the form, manner, and frequency requested, Medicare may impose a fine of up to $1000 per day, per injured party, as Civil Monetary Penalties (CMPs).

Before the MMSEA was enacted, Medicare relied on settling parties to notify it when settling a case for a Medicare beneficiary. This process allowed Medicare to gather some information about the case and look for instances where it had made payments for treatment and RXs where there was a primary payor involved (i.e. Carrier, TPA, Self-Insured, etc). Because this information was not required by law, Medicare put in place a mandatory insurer reporting (MIR) process that requires primary payors to provide over 200 data fields with information about the case and all the parties involved. The collection of that data is then used to place a marker in Medicare’s system. This marker will help Medicare determine if treatment or prescriptions are related to a settlement involving a primary payor. Medicare will then use that marker as a reference point to deny paying for Medicare-covered, case-related treatment. There have been improvements made to the system over the last 16 years, and the number of data fields that must be reported has increased over time.

Fast forward to April 4th, 2025. Medicare now requires that if a MSA allocation was prepared on the case, that information must be entered into the WCMSA field during the reporting process. Medicare expects the MSA amount to be spent on Medicare-covered, case-related treatment per CMS’s guidelines for MSA funds. In the past, Medicare was unaware of the MSA amount if the case was not submitted to CMS for approval. CMS has seen a steady decline in cases being submitted for approval, and essentially had no viewership on the MSA figure, which makes it difficult to know when Medicare would step in and become the primary payor again for Medicare-covered, case-related items. As of April 4th, 2025, Medicare now requires this information to be provided to them for WC settlements, regardless of whether a MSA allocation was submitted to them for approval.

Medicare is now armed with all the information they need, regardless of submission status, to review and deny payments for Medicare-covered, case-related items. This will force the individual to use those MSA funds for Medicare-covered, case-related treatment until they are exhausted. Accurate accounting and annual attestations (post-settlement) must be provided to Medicare before they step in as the primary payor. If the beneficiary fails to provide the necessary information, Medicare will continue to deny payments until proper documentation is provided that shows the WCMSA funds were spent in compliance with Medicare guidelines. If those funds were misappropriated, Medicare will continue to deny payment for any Medicare-covered, case-related treatment and RXs until the funds are replenished and spent according to Medicare’s guidelines.

In 2017, CMS indicated, “Although beneficiaries may act as their own administrators, it is highly recommended that settlement recipients consider the use of a professional administrator for their funds.” Now that the WCMSA field is required as part of the Mandatory Insurer Reporting process, it is critical to discuss the proper administration of the MSA funds during the settlement process.

If you have any questions or would like more information about how Medivest can protect future Medicare benefits for the injured worker, please contact us at info@medivest.com or contact our office at 877-725-2467.

 


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11/Apr/2025

The Centers for Medicare & Medicaid Services (CMS) presentation from the March 27, 2025, Introduction to Medicare Secondary Payer for Beneficiary Representatives webinar has been released and can be found here.

Presentation Overview

The intention of this webinar serves as a high-level introduction to the Medicare Secondary Payer (MSP) statute for beneficiaries and their representatives. Topics discussed include what the MSP is, including coordination of benefits, MSP types, the basics of the recovery process, and the Medicare Secondary Payer Recovery Portal. Additional resources are also made available in the presentation in the form of links to NGHP Recovery Webpages, important contacts, and more.

Additional information about the most recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients or your company, please contact Medivest or call us at 877.725.2467.

 


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08/Apr/2025

On April 7, 2025, the Centers for Medicare & Medicaid Services (CMS) updated the MMSEA Section 111 NGHP User Guide to version 8.0. The newer version has been posted to the NGHP User Guide page, found here. The NGHP User Guide to version 8.0 replaces Version 7.9 which was released on January 17, 2025.

MMSEA III – April 7, 2025 – NGHP User Guide version 8.0 Downloads

Chapter 1: Introduction and Overview

The updates listed below have been made to the Introduction and Overview Chapter Version 8.0 of the NGHP User Guide. As indicated on prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. There are no changes for this version.

Chapter II: Registration Procedures

The update below has been made to the Registration Procedures Chapter Version 8.0 of the NGHP User Guide. As indicated in prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. To align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide.

Chapter III: Policy Guidance

The updates listed below have been made to the Policy Guidance Chapter Version 8.0 of the NGHP User Guide. As indicated in prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. To align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide.

Chapter IV: Technical Information

The updates listed below have been made to the Technical Information Chapter Version 8.0 of the NGHP User Guide. As indicated in prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide, as necessary. A clarification has been added that the reporting threshold does apply to non-trauma no-fault and workers’ compensation cases (Section 6.4). The Event Table has been updated to include three new scenarios involving MSA corrections (Section 6.6.4). To align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide.

Chapter V: Appendices

The updates listed below have been made to the Appendices Chapter Version 8.0 of the NGHP User Guide. As indicated in prior Section 111 NGHP Town Hall teleconferences, the Centers for Medicare & Medicaid Services (CMS) continue to review reporting requirements and will post any applicable updates in the form of revisions to Alerts and the user guide as necessary. To align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide. To reflect improved reporting requirements, Zip+4 section guidance has been updated (Appendix A, Appendix B, and Appendix G). To ensure consistency of data, as of October 6, 2025, the Recovery Agent TIN field is required if agent name is submitted (Appendix B and Appendix G).

270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting Non-GHP Entities Version 6.0

The email address for contacting an Electronic Data Interchange (EDI) Representative has changed to COBVA@bcrcgdit.com. However, COBVA emails coming from CMS now show the address as COBVA@mail.cms.hhs.gov (Customer Support).

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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08/Apr/2025

Centers for Medicare & Medicaid Services (CMS) has revised the WCMSA Reference Guide to reflect recent changes in CMS policy and Section 111 reporting requirements. Version 4.3, dated April 7, 2025 has three notable changes:

1) A Notice of Settlement Received letter has been added to the Guide at Appendix 5 to support the new Mandatory Workers’ Compensation Medicare Set-Aside (WMSA) reporting requirements;

2) The one year waiting period for the Amended Review of MSAs has been removed from Section 16.3; and

3) The revised Reference Guide provides additional clarity around CMS’ change of MSA submitter policies (Sections 16.3 and 19.4).

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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07/Apr/2025

The Centers for Medicare & Medicaid Services (CMS) has released the Self-Administration Toolkit for WCMSAs version 1.7 on April 7, 2025. The Toolkit replaces Version 1.6, which was released on August 1, 2024. 

To download the new Self-Administration Toolkit for WCMSA Version 1.7 click here.

Self-Administration with Additional Help

For injured parties who are considering self-administration, but also want additional consultation on the process, Medivest provides a Self-Administration Kit. With the purchase of the Medivest Medicare Set-Aside Self-Administration Kit, the injured party 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 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 keep its readers updated when such changes are announced. For questions about self-administration, professional administration or anything else regarding rules and recommendations from CMS, feel free to contact the Medivest representative in your area by clicking hereor calling us at 877.725.2467. 

 


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06/Mar/2025

CMS will be hosting an Introduction to MSP for Beneficiary Representatives webinar. The intent of this webinar is to support the attorney and beneficiary representative communities and review the basics of MSP, Group Health vs. Non-Group Health Coordination of Benefits, and MSP recovery. The presentation will be followed by a question-and-answer session.


 

Date: March 27, 2025
Time: 1:00 PM ET

Webinar Link: https://cms.zoomgov.com/j/1602933030?pwd=CS3jdG0Whh8BcACklF4Dwi3OU9zuCc.1
Passcode: 082211

Or to connect via phone:

Conference Dial In: 1-833-568-8864
Conference Passcode: 160 293 3030

Important Note: This is a public webinar and there is no pre-registration. The link above will not be active until the day of the webinar.


 

Additional information about the most recent updates from CMS can be found here. If you have questions on how topics discussed in this webinar may affect your clients or your company, please contact Medivest or call us at 877.725.2467.


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29/Jan/2025

When Medicare’s interests (past and/or future) are not considered, are you aware of the unintended consequences which may affect the parties to the settlement? The Centers for Medicare and Medicaid Services (CMS) WCMSA Reference Guide v 4.2,  found here, provides language regarding their views and remedies. Understanding CMS’ views and consequences is a good step in helping a party navigate the often-confusing settlement process as it relates to staying compliant with the Medicare Secondary Payer (MSP) statute.

Conditional Payment Recovery

Medicare has a right to seek reimbursement for the conditional payments it makes to providers where another payer may be responsible. The payment by Medicare is conditioned on Medicare taking on recovery at the appropriate time and therefore, is termed to be a “conditional payment” because it must be repaid to Medicare once the settlement occurs. However, when the conditional payments have not been repaid, Medicare may take the following actions:

Priority Right of Recovery or “Super Lien”Medicare has a Priority Right of Recovery or “Super Lien” without the need to file any notice in a court.  CMS states, “If Medicare’s interest is not considered, CMS has a priority right of recovery against any entity that received any portion of a third-party payment directly or indirectly – a right to recover or take back, that payment.”

Subrogation Rights – CMS states, “Medicare has a subrogation right to any such payment it has made.  Subrogation means the substitution of one person or entity for another. If Medicare exercises its subrogation rights, Medicare becomes a claimant against the responsible party and/or the liability insurer/medical provider to the extent that Medicare has made payments to or on behalf of the beneficiary for services related to claims against the responsible party and the responsible party’s liability insurance.  While Medicare can pursue recovery directly from the responsible party through their “pay and chase” method, utilizing subrogation is usually less common.”

Charging Interest – Additionally, Medicare may and does regularly charge interest on this type of MSP conditional payment debt when a demand has remained unpaid for 60 days. The interest rate is currently over 12%. This can be a factor in how the entities and claimants choose to address any appeals or request to waive the MSP debt. After 120 days from the debt of the demand, the MSP debt may be transferred to the Department of Treasure (DOT) for various DOT collections actions.  The most common remedies exercised when the debt is referred to the DOT is the Treasury Off-Set Program or Private Collection Action (PCA).

Referral to the Treasury DepartmentCMS states, “When the outstanding debt has moved through Medicare’s recovery process, and it is still unpaid, the debt is referred to the Treasury Offset Program (TOP) for further collection activities. The TOP may garnish the beneficiary’s Social Security benefits or seize the primary plan’s federal tax refund.”

Referral to the Department of Justice – CMS states, The Centers for Medicare and Medicaid Services (CMS) may refer the debt to the Department of Justice (DOJ) for legal action if it determines that the required payment or a properly documented defense has not been provided. The law authorizes the Federal government to collect double damages from any party that is responsible for resolving the matter, but which fails to do so.”

CMS’s Views – NSMSA / EBMSA / WCMSA

CMS has stated that there are no statutory or regulatory provisions requirements to submit a WCMSA amount proposal to CMS for review. As a result, there has been an increase in defendants using Non-Submit Products – MSAs (NSMSA) or Evidence-Based MSAs (EBMSA) instead of having the traditional WCMSA Arrangement prepared and submitted to CMS for review. While there are some similarities in these reports in respect that they each attempt to estimate the future Medicare covered medicals which are likely to be encountered by the injured party after settlement, there are substantial differences in the projection methodology that could open settling parties up to risks.

Non-Submit Medicare Set-Aside (NSMSA) Report – The NSMSA report meets workload review thresholds but is a report (by definition) is not submitted to CMS for review and approval.  The defendant may decide to use a non-submit MSA allocation report to speed up the settlement process and because it often projects a lower amount of money for the claimant’s future injury-related Medicare covered medicals (FIRMCM) than a traditional WCMSA written by the WCMSA Reference Guide standards.

Evidence-Based Medicare Set-Aside (EBMSA) Report – The EBMSA report is based on the injured party’s medical records and research trends. When an EBMSA report is used, the parties do not intend to submit the EBMSA to CMS for review and approval. The report’s projection would be guided by evidence-based medicine standards with the treating physician’s recommendations.  It uses established evidence-based standards of care to create a medically and legally defensible assessment of the injured party’s future medical needs.

WCMSA Arrangement – The WCMSA report follows CMS’ guidelines when preparing reports and submitting to CMS for review.  As part of CMS’ guidelines, they required the report to use average wholesale prices (AWP) to price Medicare Part D drugs, confirm jurisdiction to apply correct fee schedules for treatments, and to use ICD-10 mandatory diagnosis and procedure codes. When reviewing the WCMSA, CMS assesses whether the proposed amount of funds set aside for future medical expenses aligns with Medicare’s standard of care protocols, essentially checking if the proposed treatment plan and cost are considered reasonable and appropriate based on Medicare guidelines for similar conditions.

CMS’ Views – Traditional WCMSAs Arrangements

Below are some of CMS’ views found in section 3.0 of the WCMSA Reference Guide:

  • “Medicare may also refuse to pay for future medical expenses related to the WC injury until the entire settlement is exhausted.”
  • “The WCMSA amount review process is the only process that offers both Medicare beneficiaries and Workers’ Compensation entities a finality, with respect to obligation for medical care required after a settlement, judgement, award, or other payment occurs.”
  • “Once the CMS-approved set-aside amount is exhausted and accurately accounted for to CMS, Medicare will pay primary for future Medicare-covered expenses related to the WC injury that exceed the approved set-aside amount.”

Changes to WCMSA Ref Guide -Section 4.3 – Non-Submit MSA Products

The Medivest blog written on February 3, 2022, titled The Further Review of Section 4.3 of the New WCMSA Reference Guide found here, which outlines the consequences when using the Non-Submit MSA’s products. Below are some of the primary takeaways from that blog:

  • The party with the most to lose is the beneficiary. The primary consequence referenced in 4.3 is denial of payment for the beneficiary’s injury-related care in the event of MSA exhaustion. CMS says it will continue to deny payment until the entire net settlement has been fully spent down (not the total MSA amount). This could occur in events of permanent exhaustion or during temporary exhaustion periods, when the beneficiary’s MSA is exhausted until the next funding payment is received. Keep in mind that this doesn’t apply to MSAs that do not meet the review threshold. Also, there is an appeal process for denial of payment. But the greatest risk-bearer is the applicant.
  • Since MSA exhaustion represents the greatest risk to the applicant, a program of proper funds administration is preferable. A burden shift to Medicare can only occur once Medicare becomes the primary payer. An MSA that remains solvent will maintain Medicare’s payment position as secondary indefinitely. While it is impossible to foresee every expense that an MSA may incur over an applicant’s lifetime, a properly funded MSA in the hands of a competent administrator is the best protection of the interests of both Medicare and the applicant.
  • Thoughtful consideration should be given to the adequacy of an evidence-based or non-submit program. It is entirely possible to produce a fully adequate and reasonable MSA without CMS’s review and approval. However, not all products are created equally. It’s important to be confident that the methodology in use produces MSAs that consider Medicare’s interests sufficiently.

Mismanagement of WCMSA Accounts

An injured party may choose to self-administer their WCMSA funds or have it professionally administered. However, in either case when the funds have not been properly managed and have been misspent, the consequences could be:

  • If the WCMSA account is not set up, the beneficiary’s Medicare eligibility could be in jeopardy at least to the extent of the injury related FIRMCM claims.
  • Funds may need to be added to the WCMSA before Medicare pays for FIRMCM.
  • Medicare can deny payment of future injury-related medicals if the WCMSA funds are not properly used or exhausted.
  • If the carrier fails to report ORM and/or TPOC/Settlements timely, the carrier may be fined for Civil Monetary Penalties starting in April of 2025 as described in a previous blog. If attestations are not timely delivered to CMS for WCMSA’s, Medicare may deny injury-related treatment until reporting is corrected.

 

Need for Professional Administration

The mismanagement of funds can negatively affect the beneficiary’s Medicare benefits and delay treatment. That’s why hiring a Professional Administrator can help remove the burden from the injured party/beneficiaries from paying claims, managing funds, and providing attestation report to CMS. Keep in mind CMS states, “Although beneficiaries may act as their own administrators, it is highly recommended that settlement recipients consider the use of a professional administrator for their funds.”

How to Avoid Medicare’s Consequences

  • Call Medivest 877.725.2467 to speak with one of our case consultants who will help you navigate a plan that evaluates Medicare’s past and future interests in a settlement or hopeful settlement.
  • Medivest investigates and assists with the resolution of Medicare’s conditional payments in WC claims on behalf of an employer/carrier/TPA and can act as the eyes of the claimant to make sure that the carrier is paying its share of accepted injury related conditional payments.
  • Medivest investigates and assists with the resolution of Medicare’s conditional payments, or those of Medicare Advantage Plans (Part C), Prescription Drug Plans (Part D), Department of Veterans Affairs (VA), TRICARE, ERISA, and privately administered insurance plans for liability cases when referred to by the plaintiff’s attorney.
  • Medivest prepares WCMSA, LMSA and Medical Cost Projection (MCP) reports
  • Medivest submits WCMSA allocation reports to CMS for review when allowed and desired.
  • Medivest professionally administers MSA Funds for WC and Liability MSAs.  Hire Medivest for Professional Administration to manage the MSA funds.

About Medivest

Founded in 1996, Medivest is a national Medicare Secondary Payer (MSP) compliance company and provider of settlement solutions. Our focus is assisting anyone settling a workers’ compensation or personal injury claim to understand their obligation to consider Medicare’s interests under federal law. Medivest provides pre- and post-settlement solutions that help mitigate exposure from that obligation. Contact us today at 877-725-2467 or at medivest.com/contact-us.


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22/Jan/2025

On January 17, 2025, CMS updated its Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide to reflect a new policy in Section 4.2 to no longer review zero-dollar WCMSAs as of July 2025. Other announced changes in the WCMS Reference Guide, now in version 4.2, include an update of WCRC Review Considerations in Section 9.4.3 and corrected example calculations for Intrathecal Pump, Spinal Cord Stimulator, and Peripheral Nerve stimulator replacements were made in Section 9.4.5.

On January 21, 2025, CMS indicated via email and its website that it will be implementing two operational changes to the WCMSA review process in the first half of 2025 as follows:

Amended Reviews: Currently, amended review requests cannot be submitted until 1 year after a WCMSA case has been approved. Effective April 7, 2025, amended review requests will be allowed at any time after a WCMSA case is approved.

Zero-Dollar Set-Asides: Effective July 17, 2025, CMS will no longer accept or review WCMSA proposals with a zero-dollar ($0) allocation. Entities should still consider the parameters available in the WCMSA Reference Guide (PDF) to determine whether a zero-dollar WCMSA allocation is appropriate and should maintain documentation to support that allocation.”

As a refresher, the WCMSA Reference Guide, in Section 4.2, which describes when a zero-dollar MSA is appropriate, used to list three conditions to determine when Medicare’s future interests in a Workers’ Compensation settlement had been protected. The Reference Guide’s updated Section 4.2 has been revised significantly, and now includes only two conditions to indicate when Medicare’s future interests are protected in a WC settlement with several examples of when the second condition is met as listed in the text below:

4.2 Indications That Medicare’s Interests Are Protected

Submitting a WCMSA proposed amount for review is never required. But WC claimants must always protect Medicare’s interests. A WCMSA is not necessary under the following conditions because when they are true, they indicate that Medicare’s interests are already protected:

a) The facts of the case demonstrate that the injured individual is only being compensated for past medical expenses (i.e., for services furnished prior to the settlement); and

b) There is no evidence that the individual is attempting to maximize the other aspects of the settlement (e.g., the lost wages and disability portions of the settlement) to Medicare’s detriment.

These conditions may be demonstrated through one of the following:

• The individual’s treating physician documents in medical records that to a reasonable degree of medical certainty the individual will no longer require any treatments or medications related to the settling WC injury or illness; or

• The workers’ compensation insurer or self-insured employer denied responsibility for benefits under the state workers’ compensation law and the insurer or self-insured employer has made no payments for medical treatment or indemnity (except for investigational purposes) prior to settlement, medical and indemnity benefits are not actively being paid, and the settlement agreement does not allocate certain amounts for specific future or past medical or pharmacy services as a condition of settlement; or

• A Court/Commission/Board of competent jurisdiction has determined, by a ruling on the merits, that the workers’ compensation insurer or self-insured employer does not owe any additional medical or indemnity benefits, medical and indemnity benefits are not actively being paid, and the settlement agreement does not allocate certain amounts for specific future medical services; or

• The workers’ compensation claim was denied by the insurer/self-insured employer within the state statutory timeframe allowed to pay without prejudice (if allowed in that state) during investigation period, benefits are not actively being paid, and the settlement agreement does not allocate certain amounts for specific future medical services.

In addition, if a settlement leaves WC carriers with responsibility for ongoing medical and prescription coverage once the settlement funds are fully spent, then a WCMSA is not necessary.

Effective July 17, 2025, CMS will no longer accept or review WCMSA proposals with a zero- dollar ($0) allocation. Entities should consider the above parameters in determining whether a zero-dollar WCMSA allocation is appropriate and maintain documentation to support that allocation.

Notes:

… If Medicare made any conditional payments for WC injury-related services furnished prior to settlement, then Medicare will recover those payments. In addition, Medicare will not pay for any WC injury-related services furnished prior to the date of the settlement for which it has not already paid.

CMS will not issue “verification letters” stating that a WCMSA is not necessary.

In instances where the above conditions are not met, CMS’ voluntary, yet recommended, WCMSA amount review process is the only process that offers both Medicare beneficiaries and Workers’ Compensation entities finality, with respect to obligations for medical care required after a settlement, judgment, award, or other payment occurs. When CMS reviews and approves a proposed WCMSA amount, CMS stands behind that amount. Without CMS’ approval, Medicare may deny related medical claims, or pursue recovery for related medical claims that Medicare paid up to the full amount of the settlement, judgment, award, or other payment.”

The second to last paragraph of Section 9.4.3 was substituted from:

“The WCRC relies on evidence-based guidelines for prescription medication and medical treatment allocations; however, these are guidelines, not rules. The final determination is also based on the claimant’s past use and future recommended treatment as supported by the medical records and by current peer-reviewed medical literature. See Appendix 4 for a list of resources the WCRC uses.”

to the following:

“The WCRC final determination relies on the claimant’s past use and future recommended treatment as supported by the medical records. Evidence-based guidelines for prescription medication and medical treatment allocations and current peer-reviewed medical literature are also reviewed; however, these are guidelines, not rules. See Appendix 4 for a list of resources the WCRC uses. Treating provider plans are given preference where the two are at odds.”

The corrected example calculations in 9.4.5 for intrathecal (IT) pump pricing should be reviewed by allocators and their price coders to make sure that WCMSA pricing for IT pumps is consistent with the corrected calculations in the updated Reference Guide.

 

Take Aways:

• The new “no review” policy for zero-dollar MSA’s seems driven in large part to spirited feedback provided to CMS from the WCMSA community. There were several CMS panel discussions with MSP Network membership at the September 2024 MSP Network educational conference in Baltimore during which many of the concerns now addressed in updated Section 4.2 of the Reference Guide concerning WC cases with no payments toward denied body parts (other than during investigation periods), determinations made by WC judges/commissions at the state level, and statutory limits on payment of future medicals by WC carriers were brought up and debated.

• The drop of the one year waiting period before submitting Amended Reviews is another step toward more fair reviews by CMS and also seems to be a result of strong advocacy by those who submit allocation reports, the attorneys, who represent those entities, and the MSP Network stakeholder community at large.

• This is encouraging as it shows that CMS does listen to feedback from the MSP stakeholder community.

 

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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