In most cases in which a Medicare set-aside is needed, the workers’ compensation insurer will hire a vendor to come up with a WCMSA proposal. The vendor will review the available medical records and project what your future medical treatment will cost over the rest of your life.
Full Answer
How do I submit a Medicare set-aside arrangement (WCMSA)?
Purpose. The Medicare Set-aside Certified Consultant™ (MSCC™) credential is designed to identify those professionals who work within the workers' compensation benefit system as …
Where do I Send my WCMSA claim to Medicare?
Dec 01, 2021 · A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is an agreement between Medicare and the Medicare beneficiary to take a portion of a Workers’ …
How is a WCMSA handled by CMS?
Dec 08, 2020 · Usually, setting up a Medicare set-aside agreement is voluntary and not federally mandated. To be eligible to set up a WCMSA, a person must:. either be a Medicare beneficiary …
Can a Medicare Beneficiary self-administer a WCMSA?
WCMSA Portal. The Workers’ Compensation Medicare Set-Aside Portal (WCMSAP) allows electronic submission of Workers’ Compensation Medicare Set-Aside Arrangements …
How do you self administer a Medicare set aside?
How does a Medicare set aside work?
What is an MSA Medicare set aside?
Will Medicare cover a work related injury?
How do I set up an MSA account?
- Join: Enroll in a qualifying high-deductible Medicare Advantage MSA Plan.
- Set up your MSA: Next, you'll select your health plan provider and the provider will open your account with Optum Bank®.
- Get your money: Medicare will deposit a certain amount of money each year for your health care.
What is an MSA payment?
What is a MSA release?
What happens to Medicare set aside funds upon death?
What is a non submit MSA?
Is Medicare set aside taxable?
Does Medicare pay for injuries?
Do you have to repay Medicare?
Account Set-Up and Administration
If the Medicare beneficiary decided to self-administer their WCMSA, they should review the Self-Administration Toolkit for WCMSAs available in the Downloads section at the bottom of this page.
Where to Get Help
For questions about annual attestations or annual accountings, contact the Benefits Coordination & Recovery Center (BCRC). See the Contacts page for BCRC phone numbers.
Submission Process
A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) can be submitted electronically through the WCMSA Portal (WCMSAP), or sent by mail, either as paper documents or CD. Using the WCMSAP for your WCMSA submission is the recommended approach as it is more efficient than mailing this information.
Submission Acknowledgement
WCMSAP submitters receive immediate confirmation of successful submission on the portal. Additionally, WCMSAP submitters and paper/CD submitters receive an acknowledgement letter. If you do not receive an acknowledgement letter, please contact the Benefits Coordination & Recovery Center (BCRC). See the Contacts page for BCRC phone numbers.
Review and Decision Process
After a WCMSA proposal is submitted, the WCRC performs an independent review of the proposed medical and prescription drug costs. Evaluation tools are used to determine if the proposed WCMSA amount is adequate to protect Medicare’s interests.
Regional Office Determination
When the RO receives the case, they review the submission package and the WCRC recommendation. The RO makes a determination as to the final WCMSA amount and notifies the submitter of their decision, by letter for paper/CD submissions, or e-mail alert, for WCMSAP submissions. The submitter may receive any of the following notifications:
Request for Re-Review
If the submitter believes the recommended value is the result of an error, they may be eligible to submit a re-review request. For information on re-review requests, please see the WCMSA Reference Guide which is available in the Downloads section at the bottom of the WCMSA page.
What is a workers compensation set aside?
A Workers’ Compensation Medicare Set-aside Arrangement (WCMSA), often called “Medicare set-aside,” involves some of the money from a workers’ compensation settlement being allocated for future costs that Medicare would typically cover. Medicare has strict guidelines about how a person can use the funds in their set-aside account.
What is MSA in WCMSA?
When a person has an WCMSA, some money awarded in a workers’ compensation settlement is placed in a separate account, called an MSA, to cover future medical needs related to the illness or injury in the claim. A person needs to use this money for Medicare-approved services.
Does Medicare cover MSA?
Medicare helps cover a range of healthcare costs for adults ages 65 and older, as well as for some younger adults with specific health conditions. If a person receives a settlement for a workers’ compensation claim, a portion of the money is put into a WCMSA account — called an MSA — for future medical care.
Does Medicare cover medical expenses?
Under Medicare Secondary Payer legislation, in some instances, Medicare does not have the primary responsibility to cover medical costs, and other available insurance is responsible for the coverage before Medicare.
Does Medicare cover prescription drug costs?
The costs must be among those that Medicare typically covers, including prescription drug expenses. Individuals may not use the funds for any services that Medicare does not cover. Individuals must keep copies of receipts and bills and report all of their WCMSA-related costs to the CMS each year.
WCMSAP Features & Benefits
The WCMSAP provides you with the following features and related benefits:
How to Access the WCMSAP and User Documentation
The WCMSAP application can be accessed at: https://www.cob.cms.hhs.gov/WCMSA/login. For more information on how to register and use this application, please see the WCMSAP User Manual which is available under the ‘Reference Material’ menu option of the WCMSAP application.
WCMSAP Training Materials
CMS has made available a curriculum of computer-based training (CBT) courses for WCMSAP users. These courses provide in-depth training on WCMSAP registration and use of the WCMSAP. You can access these CBTs from the Dynamic List located on the bottom of this page.
For assistance with WCMSAP Issues
Contact the EDI Department at 1-646-458-6740 for issues related to the WCMSAP (e.g., password resets, or the status of your WCMSAP account registration).
Does Medicare pay conditional payments?
Medicare is required by statute (42 U.S.C. § 1395y(b)) to seek reimbursement for conditional payments related to the settlement. Further, Medicare is prohibited from making payment where payment has been made (that is, where the beneficiary obtains a settlement, judgment, award, or other payment).
What to do if there is no settlement?
If there are no settlement documents, the reviewer will use the payout method as requested in writing by the claimant or claimant’s attorney. If there is no such written request, the reviewer will use the method stated in the submitter cover letter. The default method, should all else fail, is the lump sum payout.
What is a life care plan?
A Life Care Plan is a dynamic document based on published standards of practice, comprehensive assessment, data analysis, and research that provides an organized concise plan for current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic health needs.
What is DME in medical terms?
DME includes oxygen and respiratory therapy equipment, hospital beds, wheelchairs and other walking aids, and other such devices and equipment used in the home or in an institution serving as a home. End-stage renal disease . A person with ESRD may qualify for Medicare benefits. Food and Drug Administration .
Is Medicare a secondary insurance?
With the addition of the MSP provisions to federal law in 1980 (and subsequent amendments), Medicare is secondary payer to group health plan insurance in specific circumstances, but is also secondary to liability insurance (including self - insurance), no-fault insurance, and Workers’ Compensa tion. National Drug Code .
Is Lyrica a neuropathic pain medication?
Example 1: Lyrica (Pregabalin) is cited in MicroMedEx for an off-label medication use related to neuropathic pain from spinal cord injury, and a number of scientific studies indicate that Pregabalin shows statistically significant positive results for the treatment of radicular pain (a type of neuropathic pain).
What is Medicare set aside?
A Medicare Set Aside (MSA) account is an additional amount of money, added to your workers’ compensation settlement, to cover all future injury-related medical expenses that would normally be paid by Medicare.
Can MSA funds be used for medical expenses?
The injured party can use their MSA funds on Medicare-approved expenses related to their injury . This can include doctor bills, prescriptions, durable medical equipment, home healthcare, and more. The injured party cannot use their MSA funds for anything other than these expenses.
What is MSA in Medicare?
A proposed MSA is an allocation report showing items that are related to the injury and would be covered by Medicare. MSA’s can be submitted to Medicare for review and approval if they are significant to meet Medicare’s review thresholds. Again, the process of review and approval is voluntary.
What is MSA in insurance?
A proposed MSA is a cost projection of all lifetime medicare covered items for the work injury that may be needed based on the prior two years medical and pharmacy records. The Workers’ compensation insurance company pays for this cost projection.
How long does it take for a CMS approval to be approved?
The approval can take 3 to 6 months once all items have been submitted to the CMS for approval.
What happens if you don't manage your MSA?
If you do not properly manage your MSA account, you could severely jeopardize Medicare paying for your future medical care. Consequences include denial of future bills from Medicare if your funds exhaust and being required to repay your MSA account for expenses that were paid for that are not covered by Medicare.
Why do we need MSA?
The reason for creating an MSA is to designate a certain amount from the settlement as “future medical money” to cover injury-related medical expenses. The MSA is to be spent fully on those expenses prior to Medicare paying for them.
What is MSA account?
MSA Accounts require detailed record keeping and reporting to CMS (Centers for Medicare and Medicaid Services), and have many restrictions about how the money in the account can and cannot be spent. Medicare rules dictate that you only pay for medications and procedures that are covered by Medicare and that you only pay the approved price for each bill. They also require that you keep records and receipts, and that you report all expenses to Medicare. If mistakes are made -- the injured person can risk future entitlement to Medicare benefits.
Is Medicare a secondary payer?
Medicare is always a secondary payer to liability insurance ( including self-insurance), no-fault insurance, and workers’ compensation benefits . The law precludes Medicare payment for services to the extent that payment has been made, or can reasonably be expected to be made promptly, under liability insurance (including self-insurance), ...
What is MSA in medical?
An MSA is a financial arrangement that allocates a portion of a settlement, judgment, award, or other payment to pay for future medical services. When future medical care is claimed, or settlement, judgment, award, or other payment releases (or has the effect of releasing) claims for future medical care; it can reasonably be expected ...
What happens if Medicare runs out of money?
If the money does run out, Medicare will step in and help, but only if the MSA Account has been in compliance with every rule and regulation that Medicare has including spending, record keeping and reporting. It is very easy to jeopardize your future Medicare eligibility for your injury.
Submission Process
- A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) can be submitted electronically through the WCMSA Portal (WCMSAP), or sent by mail, either as paper documents or CD. Using the WCMSAP for your WCMSA submission is the recommended approach as it is more efficient than mailing this information. For information about how to use the WCMSAP,...
Submission Acknowledgement
- WCMSAP submitters receive immediate confirmation of successful submission on the portal. Additionally, WCMSAP submitters and paper/CD submitters receive an acknowledgement letter. If you do not receive an acknowledgement letter, please contact the Benefits Coordination & Recovery Center (BCRC). See the Contactspage for BCRC phone numbers.
Review and Decision Process
- After a WCMSA proposal is submitted, the WCRC performs an independent review of the proposed medical and prescription drug costs. Evaluation tools are used to determine if the proposed WCMSA amount is adequate to protect Medicare’s interests. During its review, the WCRC may send development letters (paper/CD submitters) or e-mail alerts (WCMSAP submitte…
Regional Office Determination
- When the RO receives the case, they review the submission package and the WCRC recommendation. The RO makes a determination as to the final WCMSA amount and notifies the submitter of their decision, by letter for paper/CD submissions, or e-mail alert, for WCMSAP submissions. The submitter may receive any of the following notifications: 1. Approval letter if t…
Request For Re-Review
- If the submitter believes the recommended value is the result of an error, they may be eligible to submit a re-review request. For information on re-review requests, please see the WCMSA Reference Guide which is available in the Downloads section at the bottom of the WCMSApage. If the case qualifies, the re-review request should be submitted as follows: 1. For a proposal that w…