CMS Updates to Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide

CMS recently released an update to the Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (Version 3.9, updated May 15, 2023), bringing about significant changes and improvements. Let's delve into the key updates:

1. Amended Review: The most notable change is the removal of the maximum time limit for eligibility in the amended review process. CMS previously limited reviews to cases where an approved Medicare Set-Aside (MSA) amount had been issued at least 12 months but no more than 72 months prior. Now, the end time limit has been removed entirely, although the file must be at least 12 months old since the prior MSA determination. This significant change provides an opportunity for re-evaluation of much older claims, giving parties the chance to settle disputes related to prior MSA amounts.

2. Medical Review Guidelines: CMS introduced guidance for the replacement of Peripheral Nerve Stimulators (PNS) and clarified replacement frequency calculations for intrathecal pump (IT pump) and spinal cord stimulator (SCS). When the device is not yet implanted, CMS assumes it will be within the first year following settlement or at the next routine interval for replacement, allowing one year to be subtracted from life expectancy before the replacement calculation. If the device is already implanted, the difference from the last implantation is subtracted from the life expectancy prior to the replacement calculation. This clarification enables more realistic replacement calculations, particularly for cases with already implanted devices.

3. Approval Process: CMS Regional Offices are no longer responsible for approving initial determinations. Instead, the Workers Compensation Review Contractor (WCRC) will complete their review, make recommendations, and CMS will issue an approval letter without additional review. The case will then be transferred to the appropriate Regional Office to await the final settlement documents.

Other, miscellaneous updates include: changes in contact information for customer service, updated ZIP codes, and links to CDC Life Tables.

We are delighted with the changes that CMS has made, particularly those changes that clarified the allocation of implantable devices and extended the amended review time frame.

If you have any questions or concerns about the recent update in the CMS WCMSA Reference Guide or believe you have a stagnant claim (or multiple claims!) you believe could benefit from an amended review, please do not hesitate to reach out to us. We are ready to assist you with any Medicare compliance issues you may have!