CMS Publishes Latest Version of Work Comp MSA Reference Guide

Rafael Gonzalez, Esq.
Vice President, Strategic Solutions

Dated December 14, 2015, the Center for Medicare and Medicaid Services (CMS) recently published its updated Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide, Version 2.4.

First published in March 2013, and since revised on November 2013 (version 2.0), February 2014 (version 2.1), April 2014 (version 2.2), January 2015 (version 2.3), and now December 2015 (version 2.4), the guide was written 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.” Since its first publication, the WCMSA Reference Guide “reflects 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.”

Version 2.4 of the Guide now includes updates to accommodate Non-Group Health Plan (NGHP) Ongoing Responsibility for Medicals (ORM) recovery activities. This is based on the August 25, 2015, and September 17, 2015, CMS announcements that starting October 5, 2015, files would be transitioned to the Commercial Repayment Center (CRC), as CMS would start pursuing recovery from applicable plans, liability insurance (including self-insurance), no-fault insurance, and workers’ compensation law or plan, as the identified debtor. Those announcements stated, “CRC will identify and recover Medicare’s conditional payments for all new recovery cases where CMS pursues recovery directly from an applicable plan as the identified debtor. CMS will pursue recovery directly from an applicable plan as the identified debtor when an applicable plan reports that it has ongoing responsibility for ORM or otherwise notifies CMS of its primary payment responsibility.”

As a result, Version 2.2 of the WCMSA Reference Guide was amended to incorporate NGHP ORM recovery activities. Very specifically, Section 2.2 of the Guide (Reporting a WC Case) was amended by adding the following:

Note: If Medicare is pursuing recovery directly from the WC insurer, the beneficiary, attorney or other representative will receive a copy of recovery correspondence sent to the WC insurer. For more information on insurer recovery, see the Non-Group Health Plan Recovery page.

This latest version of the WCMSA Reference Guide incorporates what CMS has previously announced and is now taking place when Medicare is pursuing recovery directly from the self-insured employer or WC insurer, also providing notice to the beneficiary, attorney, or other representative of such recovery effort directly from the original primary payer or applicable plan. As always, Helios Settlement Solutions will continue to track and monitor any changes affecting Medicare Secondary Payer compliance and keep you updated as to its claims handling potential effects. Should you have any questions regarding these changes, or if we can be of any help regarding any issue pertaining to MSP compliance, please contact us at 888.672.7674, or at contactus@helioscomp.com.

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About Rafael Gonzalez

As vice president of strategic solutions, Rafael Gonzalez serves as a thought leader on all aspects of Medicare and Medicaid compliance issues, including mandatory insurer reporting, conditional payments resolution, Medicare set aside allocations, CMS approval, and professional administration of Medicare set asides and special needs trusts. Prior to joining Helios, over the last 30 years, Rafael served as director of Medicare & Medicaid compliance and post settlement administration for Gould & Lamb in Bradenton, Florida. Before that, he served as chief executive officer for the Center for Lien Resolution, the Center for Medicare Set Aside Administration and the Center for Special Trusts Administration in Clearwater, Florida. Prior to that, he served as corporate counsel for FCCI Insurance, a workers’ compensation/property casualty insurance company in Sarasota, Florida. And before that, he practiced social security disability, workers’ compensation, longshore and personal injury law in Tampa, Florida. Rafael Gonzalez received his Bachelor of Science degree from the University of Florida and his Jurisprudence Doctorate degree from the Florida State University.

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