Workers' Compensation Medicare Set-Aside Arrangement (WCMSA) Frequently Asked Questions |
CMS received notice that you settled your workers' compensation claim, and that a part of the settlement was a WCMSA. By law, and to protect the Medicare program, Medicare may not pay for care where that care is paid for under workers' compensation. The WCMSA part of your settlement must be used instead of Medicare to pay for the necessary medical and pharmacy care that Medicare would normally cover and is related to your workers' compensation injuries or illnesses. Medicare will deny payment for claims that are related to these work-related injuries or illnesses. A WCMSA is a financial arrangement that sets aside a portion of your workers' compensation settlement to pay for your future medical needs. To protect Medicare's interests, the WCMSA must be "exhausted appropriately" (that is, fully and correctly spent on medical and pharmacy care for the settled work-related injuries or illnesses) before Medicare resumes paying for such care. It does not affect coverage for anything except the settled injuries or illnesses. You can only use WCMSA funds for expenses related to the injuries or illnesses addressed in your settlement that would normally be paid by Medicare. This includes services such as doctor's visits and medications to treat the injuries or illnesses. Payments for services or items that Medicare does not cover (for example, transportation costs) are not an appropriate use of WCMSA funds and are not accepted as evidence of appropriate exhaustion if you need Medicare to resume paying for related care. You will have to pay for these items and services using other funds. Also, using WCMSA funds for items not normally covered by Medicare may make Medicare stop paying for treatment for your settled injuries or illnesses until you can "attest to appropriate exhaustion" of an amount equal to the WCMSA amount - that is, show that you have completely spent that amount of money on care for your settled injuries or illnesses that Medicare would normally have covered. WCMSA funds are paid by the workers' compensation plan. For any WCMSA or settlement funding issues or questions, you need to contact your workers' compensation plan. The WCMSA funds must be deposited into an interest-bearing bank account in your name. This account must be separate from any other banking accounts, and the funds may only be used to pay for your work-related injury or illness treatment. You will pay medical providers such as doctors and pharmacies directly from this account. For details on using the account, please review the WCMSA Reference Guide and the WCMSA Self-Administration Toolkit at http://go.cms.gov/wcmsa on the CMS website. Every year, on the anniversary of your settlement date, you need to fill out an annual attestation form showing the use of the fund and related income to the fund (payments, receipts, taxes or interest). Please send your annual attestation electronically on the WCMSA Portal accessed from your Medicare.gov account or mail it to the BCRC at PO Box 138832, Oklahoma City, OK, 73113. Note that an attestation submitted on the WCMSA Portal will be immediately processed. Only one paper form is provided with your Notice of Settlement letter, so please remember to make copies before filling it out. As soon as your WCMSA funds are exhausted (that is, completely spent), you must notify CMS in writing that the account is exhausted with a final attestation letter. This letter must be sent to the Benefits Coordination & Recovery Center at BCRC NGHP, PO Box 138832, Oklahoma City, OK, 73113. Once Medicare can verify that your WCMSA money has been spent appropriately, payment by Medicare for additional medical treatment of your work-related injuries or illnesses will begin. Medicare will not pay for this treatment if the WCMSA funds were improperly used; documents such as receipts may be needed to verify appropriate use of the funds. If your WCMSA is funded by your workers' compensation plan making scheduled deposits (annual payments, for example), you may need to provide attestations on an annual basis to ensure Medicare coverage between when the funds are exhausted for the year and when they are later replenished as scheduled. It depends on the terms of your settlement. If there are remaining funds in the WCMSA account at the time the recipient passes away, some settlements will allow the estate to retain the funds while others require any remaining funds be returned to the workers' compensation plan. CMS follows either the settlement agreement or your state's estate guidelines for fund liquidation after all care related to the work injuries or illnesses has been paid from the WCMSA account. More information and guidance on these and other WCMSA-related topics may be found on the CMS.gov website at https://go.cms.gov/wcmsa. |
