CMS Publishes WCMSA Reference Guide Version 2.3

ColumnsOn March 29, 2013, the Centers for Medicare & Medicaid Services (CMS) published its first Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide to “help stakeholders understand the process used by CMS for approving proposed WCMSA amounts and to serve as a reference for those choosing to submit such amounts to CMS for approval, including injured workers, employers, carriers, their attorneys, WCMSA agents or consultants, or other appointed representatives.” The WCMSA Reference Guide contains information compiled from all WCMSA Regional Office (RO) Memorandums 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.

On November 6, 2013, the WCMS Reference Guide was updated, adding material from the 4/11/2013 WCRC Town Hall presentation and the Operating Rules. On February 3, 2014, the Reference Guide was amended again, this time adding branding changes for the Benefits Coordination & Recovery Center (BCRC) transition. On April 24, 2014, section 4.1.4 on Hearing on the Merits of the Case was added, indicating that when a state WC judge approves a WC settlement after a hearing on the merits, Medicare will generally accept the terms of the settlement, unless the settlement does not adequately address Medicare’s interests.

On January 5, 2015, CMS published its latest edition of the WCMSA Reference Guide. Version 2.3 of the Guide includes the following changes:

  • Updated language to correspond with recent changes to letters.
  • Corrected reference from 42 CFR 411.46 to Section 1862(b)(2) of the Social Security Act.
  • Clarified reference to costs related to the workers’ compensation claim, rather than the compensable injury.
  • Clarified reference to future medical items and services as “Medicare covered and otherwise reimbursable.”
  • Clarified that CMS approves the WCMSA amount, not the WCMSA, upon submission of a request.
  • Correspondingly, clarified language referring to submission of a proposed WCMSA amount, rather than a WCMSA proposal.
  • Restated the comparison of fee-schedule vs. full-and-actual-costs pricing as the basis of pricing the proposed amount, rather than the basis of payment from an approved WCMSA account.
  • Clarified attestation vs. accounting wording.
  • Clarified procedural results when Medicare is not provided with information in response to a development request.
  • Removed the word “form” from references to documents that are not forms.
  • Added language to address schedule change for hydrocodone compounds from schedule III to schedule II.
  • Changed deadline for responding to development requests for submission through the WCMSA Portal to 20 from the previous 10 days.

Hydrocodone Combination Products

Hydrocodone combination products were reclassified effective October 2014 from C-III controlled substances to C-II controlled substances. Normally, C-IIIs require a new prescription after five refills or after six months, whichever occurs first. C-IIs require new prescriptions at intervals no greater than 30 days; however, a practitioner may issue up to three consecutive prescriptions in one visit authorizing the patient to receive a total of up to a 90-day supply of a C-II. WCMSA guidelines changed on January 1, 2015 for all new cases submitted after that date to allocate a minimum of 4 healthcare provider visits per year when schedule II controlled substances (including hydrocodone combination products) are used continuously, unless healthcare provider visits are more frequent per medical documentation. WCMSA Reference Guide Section

Development Requests Submitted via the WCMSA Portal

During its review, the WCRC may need to develop the case for additional information or documentation. If the submitter does not respond to the development letter within the allotted time frame (i.e., 30 days for cases submitted to the BCRC, 20 business days for cases submitted on the WCMSAP), the case is closed for lack of response. If the submitter does respond, but the response is insufficient, another request may be sent to the submitter. If more than one development request has been sent, the timestamp of the most recent request will be used to calculate the response time frame. WCMSA Reference Guide Section 9.4.1

As always, Helios Settlement Solutions will continue to monitor these changes and report on any effects or ramifications pertaining to same.

29106aeRafael Gonzalez is Vice President of Strategic Solutions at Helios. With over 25 years of experience in the workers compensation, liability, Medicare and Medicaid industry, Rafael serves as thought leader on all aspects of Medicare and Medicaid compliance, including mandatory reporting, conditional payments, and set asides. You may contact Rafael at or 813.612.5592.

Helios is the new name for Progressive Medical and PMSI. Whether pharmacy, critical care, or settlement solutions, including mandatory reporting, conditional payments, or set aside allocations, approval, and administration, to learn how our creative and innovative tools, expertise, and industry leadership can help your business shine, visit or call 800.777.3574.

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