CMS Implements Medicare Set-Aside Data Sharing for Part D Plans
by P. Czuprynski
The Centers for Medicare & Medicaid Services (CMS) recently announced that beginning in February 2026, they will share data elements, including specific prescription drug information, with Part D plans associated with an enrollee’s Workers’ Compensation Medicare Set-Aside (WCMSA). The additional data sharing is an effort by CMS to prevent Medicare Part D plans from paying for prescription medications that should be covered by an MSA.
National Drug Codes
If parties choose to seek MSA approval from CMS, the prescriptions in the approved MSA will include National Drug Codes (NDCs). Because an NDC is specific to one drug, CMS expects Part D plans to flag not only the specific NDC, but similar medications represented by the NDC. For example, 5mg of oxycodone has multiple NDCs depending on the dosage and type of administration.
Part D plans are to use NDCs and the additional data elements, to do one of the following:
Point-of-Sale Denials/Pre-Authorization
Under this option, Part D plans must use the data provided by Medicare to deny payment of prescriptions that should be covered by the MSA at the time the prescriptions are sold to the injured worker.
If denial is made at the point-of-sale, the Part D plan must coordinate with the pharmacy to provide a notice to the injured worker of their right to appeal and request a coverage determination.
When processing an appeal, CMS directs Part D plans to accept an attestation by the WCMSA administrator or injured worker that the prescription being filled is not related to the workers’ compensation injury. The Part D plan also should accept exhaustion of an MSA.
If the Part D plan has confirmed that it is a primary payer for the drug, the point-of-sale flag, initially denying payment, should be removed to avoid any further interruption of care. If an MSA is temporarily depleted, the point-of-sale edit must also follow along with the temporary depletion and replenishment.
Pay and Chase – Conditional Payments
A Part D plan is not required to set up their system to deny prescriptions at point-of-sale. However, if the Part D plan does not opt into the point-of-sale denial system, the plan must continue to follow the procedure outlined in chapter 14 of Medicare’s Prescription Drug Benefit Manual. This manual identifies the Part D plans requirements to identify and seek reimbursement for payments where another primary plan is available under conditional payment reimbursement.
From a technical standpoint, the prescription and WCMSA data will be sent on the same schedule as other monthly files provided to Part D plans, but in a new companion file called the Medicare Beneficiary Database Other Health Insurance Monthly File (MBDOHIMO). This file will include the WCMSA Case Control Number established with Medicare along with up to 12 NDCs.
Who Will This Impact?
Medicare beneficiaries who have settled a workers’ compensation claim and used Medicare’s voluntary MSA review process will be impacted the most. This is partly because Medicare will only have NDCs to transmit for cases that are resolved with an approved MSA. Medicare will not have NDCs for non-submitted MSAs.
Medicare beneficiaries could begin to see a Part D plan deny payment of drugs at the pharmacy counter beginning in February 2026. This will likely increase appeals due to denial of payment by the Part D plan. Especially in circumstances where the MSA has been temporarily exhausted.
This data sharing will also likely impact carrier/self-insureds as beneficiaries, or their attorneys, may not understand why denial of a prescription is happening and turn to the carrier/self-insured for assistance.
Moreover, this additional data may assist Part D plans in seeking reimbursement for drugs paid for prior to settlement, increasing Part D conditional payment requests directly against a carrier/self-insured.
Due to this upcoming change, it is important that Insurers, Beneficiaries, and MSA Administrators are advised of the data being shared and are prepared to handle improper denial of medications through appeals and coverage determination requests.
We will keep you updated as we learn more about the effects of this update. Should you have any questions or wish to discuss this change further, please contact us at [email protected].