07/30/2024 | Press release | Archived content
Starting April 4, 2025, CMS will require Section 111 Responsible Reporting Entities (RRE) to report several Workers' Compensation Medicare Set-Aside (WCMSA) data points for all workers' compensation settlements involving Medicare beneficiaries as part of TPOC reporting. This new reporting requirement suddenly places WCMSAs in CMS' spotlight, and insurers need to consider several important factors regarding current WCMSA practices as they prepare for this new process as follows:
Insurers will need to report WCMSA data points regarding all WC settlements involving Medicare beneficiaries. If a WCMSA is included, several data points related to the WCMSA will need to be reported - and this reporting is required regardless of whether the WCMSA was submitted and approved by CMS. Thus, even non-submit WCMSAs, evidenced based MSAs (EBMSAs), and non-threshold WCMSAs (MSAs included in settlements that do not meet CMS' $25k WCMSA review threshold for Medicare beneficiaries) must be reported. Insurers will even have to report if no WCMSA is included in the settlement.
CMS will require RREs to submit the WCMSA amount, WCMSA funding method (lump sum or annuity), initial deposit amount, anniversary (annual deposit amount), and the WCMSA period. The WCMSA case control number and professional administer EIN will be optional fields.
CMS' new process is a big deal because it will give CMS unprecedented visibility into the parties' use (and non-use) of WCMSA arrangements as a means to prevent the risk of shifting the cost and responsibility to pay for medical treatment to Medicare in WC settlements. Up until this point CMS had no true means to identify and track WCMSAs unless the WCMSA was submitted and approved by CMS. Additionally, CMS on its recent TPOC/WCMSA Q&A call made clear that while CMS will accept TPOC data with the MSA Amount reported as $0, it reserves the right to review and audit the data if it suspects cost shifting to Medicare may have occurred.
There are several key compliance points to consider. First, by collecting this information, CMS expands its capability to identify WCMSAs in settlements and mark its Common Working File to coordinate benefits. This potentially impacts Medicare beneficiary coverage when WCMSA funds are available to pay primary. Second, it is important to remember that CMS' $25k WCMSA review threshold regarding Medicare beneficiaries is NOT a "safe harbor," and CMS has indicated that its interests need to also be considered when this threshold is not met. (See, CMS' WCMSA Reference Guide, Section 8.1). Third, CMS will now have the key data points it needs to evaluate whether its interests have been adequately addressed -and, on this point, insurers may wish to reevaluate their non-threshold practices knowing that CMS has indicated that it reserves the right to use the data for this purpose when a MSA Amount is reported as $0.
Managing these upcoming changes and staying compliant does not need to be complicated. Verisk has been a leader in Medicare Secondary Payer Compliance for over 20 years and we have taken several steps to assist our partners with preparing for CMS' new TPOC/WCMSA reporting requirements as follows:
For more information on how we can help contact Brian Cowan at [email protected]. Also, be sure to review our supplementary article for a more in-depth review of CMS' new process.