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CMS Releases Version 3.0 of WCMSA Reference Guide

Posted by Genex on November 4, 2019

Keep current with new legislation and its potential effect on your organization. This regulatory update is for informational purposes only, and provides some key highlights on state initiatives that may impact the Medicare Set-Aside services Genex provides.

Last week CMS released a revised version of their Workers’ Compensation MSA Reference Guide. Version 3.0 of the Reference Guide includes a number of changes and revised processes.  

Below is a snapshot of WCMSA Reference Guide changes

  • Addresses have been corrected or clarified for reporting workers’ compensation cases; for sending yearly WCSMA account attestations; and for sending WCMSA proposals, final settlements, and re-review requests (Sections 2.2, 17.5, and 17.6).
  • “Death of a Claimant” information has been updated and standardized with the Self-Administration Toolkit for WCMSAs (Section 19.2).
  • CMS’ expectations for competent administration of WCMSA funds when “frequently abused drugs” are prescribed for a claimant have been clarified, with policy and guidance link added (Sections 17.1 and 17.3).
  • CMS has clarified how hospital fee schedules are determined (Section 9.4.3).
  • Required language for the Consent to Release form now includes indication that the beneficiary understands the intent, process, and administration of WCMSAs (Section10.2 and Appendix 6: 10 – Consent to Release Note).
  • The Life Table link has been updated (Section 10.3).
  • This guide has been updated to account for changes in the WCMSAP, which now includes a Professional Administrator role, which can upload account transactions and view account details, and the ability to submit attestations online for all others (Section17.6; minor changes throughout).
  • The timeframe for submission of amended review requests has been extended to 6 years (Section 16.2)

After reviewing Version 3.0 of the WCMSA Reference Guide we noted three standout sections demonstrating signification changes in this version of the Guide.

Section 10.2 - Consent to Release Note

Effective April 1, 2020 the consent to release must conclude language indicating that 1) the beneficiary has reviewed the submission package and 2) the beneficiary understands the intent of the WCMSA, submission process and associated administration of the WCMSA. This section of the consent form must include the beneficiary’s initials indicating their validation.

Section 16.2 - Amended Review

CMS has extended the timeframe for requesting an Amended Review by 2 years. CMS will permit a one-time request for re-review up to six years after the date of the original CMS determination. The requirements for current medical documentation and justification for the Amended Review request remain the same.

Section 17.1 Account Set-Up and Administration and 17.3 Use of the Account

CMS highly recommends professional administration where a claimant is taking controlled substances that CMS has determined are “frequently abused drugs” according to CMS’ Part D Drug Utilization Review (DUR) policy.  Opioids and benzodiazepines are designated as frequently abused drugs.

CMS expects that WCMSA funds will be competently administered according to Medicare coverage guidelines including Part D DUR policy. This changes stems from CMS 2018 policy requiring Medicare Part D sponsors to establish drug management programs in which they can limit at-risk beneficiaries’ access to coverage for frequently abused drugs.

Sections 17.1 and 17.3 certainly shine a light on CMS’ growing preference for professional MSA administration over the beneficiary self-administered MSA. Even the most competent beneficiary will be challenged in navigating CMS coverage determinations and Part D DUR policy while administering their own WCMSA funds.

To review Version 3.0 of the WCMSA Reference Guide in its entirety please click here: Reference Guide

For more information/questions about the updated to version 3.0 of the WCMSA Reference Guide or to make a referral please contact Genex MSA  1.888.GO.GENEX or msadirect@genexservices.com


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