Recap: CMS’ Introduction to WCMSAs Webinar
by M. Heberling
On June 17, 2025, The Centers for Medicare & Medicaid Services (CMS) hosted a webinar that provided basic information related to Workers’ Compensation Medicare Set Asides (WCMSAs). According to CMS, the definition of a WCMSA is “a financial agreement to set aside some portion of a workers’ compensation settlement to cover future medical expenses.” The basic purpose is to protect Medicare’s interest and to ensure future funds are available when a claimant is, or is soon to become, a beneficiary.
During the webinar, CMS primarily focused on terminology and guidelines related to the submission of WCMSAs to CMS for review and approval. However, CMS also made it clear multiple times that there are no statutes or regulations that require that a WCMSA be submitted to CMS for review. They asserted the primary benefit of submission is the certainty associated with the approval and that premature exhaustion could leave beneficiaries at risk of Medicare denying claims due to potential shifting of the burden of payment for treatment. If the parties decide to avoid the voluntary review program, then CMS still expects claimants to follow established procedures for the disposition of funds, including submitting annual attestation reports and final exhaustion notices.
Keep in mind that there are several situations when CMS does not review an MSA (even if the parties want them to do so). This includes an MSA/settlement that does not meet the workload review thresholds[1] and is not eligible for submission and, starting on July 17, when the parties seek approval of a $0 MSA.
In reference to the upcoming change in July, CMS reviewed the overarching principles that determine when a WCMSA is not necessary:
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- An injured individual is clearly being compensated for medical expenses prior to settlement; AND
- There is no evidence that the injured individual is attempting to maximize other aspects of the settlement.
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Notably, CMS will not provide confirmation that an MSA is not necessary. It will be up the settling parties to determine whether an MSA is not needed, whether a $0 MSA is needed, or whether some type of funded MSA is needed. CMS stated that their interests should always be considered in settlements even if it is a low value settlement.
Changes to Section 111 reporting rules effective as of April 2025 require the reporting of WCMSA data as part of Total Payment Obligation to the Claimant (TPOC) reporting. CMS indicated that information about non-approved WCMSAs obtained through this process will be used to coordinate benefits. They also specified that TPOC reporting may also result in a new letter being sent to the beneficiary called a “Notice of Settlement”. This informs the beneficiary that CMS is aware a WCMSA was created AND provides important information regarding the appropriate use of the MSA funds. CMS recommended that the claimant and carrier/self-insured be on the same page with respect to the MSA to avoid any interruption of Medicare services.
CMS also provided guidance on the two ways to submit a WCMSA, including electronically through the WCMSA Portal (WCMSAP) or by mail with paper/CDs. Submission through the portal is considered more efficient and recommended by CMS. If a submission is mailed, then all future correspondence must also be sent via mail, including any future Re-Reviews or Amended Reviews.
With respect to any submission, CMS indicated that 45 days are needed before a status update is requested. In our past experience, CMS has responded more quickly than that, so we are closely monitoring whether this statement signifies any change in their usual processes. CMS also asked that 200 pages or less be submitted for review, which also appears to be a change from standard practice, so we are monitoring this as well.
If you have any questions about the topics covered during the webinar, or about which MSA type may best consider Medicare’s interests, please contact our Settlement Consulting team at [email protected].
[1] Workload review thresholds: When a claimant is a Medicare beneficiary and the estimated total settlement exceeds $25,000 OR when a claimant has a reasonable expectation of Medicare enrollment within 30 months and the estimated settlement is over $250,000.