CMS issues WCMSA Reference Guide Version 2.8

by | May 15, 2019

October 5, 2018 
by Donna Mize, MSCC

As an established Medicare Secondary Payer compliance services provider, one of our goals is to keep clients and the property and casualty insurance industry informed of changes affecting MSP compliance.

On October 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released an update to the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (version 2.8). The notable changes are as follows:

  1. As required by Section 501 of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015, CMS will discontinue all Social Security Number (SSN)-based Medicare identifiers and distribute a new 11-byte Medicare Beneficiary Identifier (MBI)-based card to each Medicare beneficiary by April 2019. All fields formerly labeled as Health Insurance Claim Number (HICN) are now labeled as “Medicare ID” and can accept either a HICN or the new MBI.
    • Page 3 of the WCMSA Reference Guide refers to this update when contacting the Benefits Coordination & Recovery Center (BCRC) to confirm the injured person’s Medicare ID (HICN, MBI or SSN).
    • Page 33, under Section 05 – Cover Letter (WCMSA submission letter) indicates: Claimant’s Medicare ID (HICN or MBI) as displayed on their Medicare card or their SSN, if not yet entitled to Medicare, is required in the submission.
    • Page 63, Appendix 2: The Abbreviations List now includes MBI – Medicare Beneficiary Identifier.
    • Page 67, an update to the definition of Social Security Number: The SSN is an identification number issued by the Social Security Administration and used instead of a Medicare ID (HICN or MBI) when the Medicare ID is not present.
    • All of the sample letters found in Appendix 5 change SSN or HICN to Medicare ID or Medicare ID/SSN.
  2. An updated link to the CDC Life Expectancy Table is located on page 41 under Section 10.3, number 7:
  3. An update to the jurisdiction and calculation method for medical reviews (Table 9-1 and Table 9-2):
    • Table 9-1 added one additional scenario in its order of precedence, number 6, stating: If the WC carrier’s attorney does not have an address in the state in which the WC claim was filed, then the pricing will be based on the zip code of the injury address.
    • Table 9-2 is a completely new table for the WCMSA Reference Guide.
      • If a case is filed with the U.S. Department of Labor Office of Workers’ Compensation Programs (OWCP); pricing is based using the OWCP Fee schedule
      • If submitted documentation indicates that a proposed WCMSA amount is based upon a Longshore Harbor Workers’ Compensation Act settlement; pricing is based on the OWCP fee schedule for the zip code of claimant’s residence, unless the submitter specifies actual charges
      • If a state WC fee schedule does not exist based on the jurisdiction evaluation above (Indiana, Iowa, Missouri, New Jersey, Virginia, and Wisconsin); Pricing is based using actual charges, even if the submitter proposed the use of a fee schedule
      • If a state WC fee schedule exists based on the jurisdiction evaluation above; Pricing is based on the most current version of the fee schedule posted publicly

As an established Medicare Secondary Payer compliance services provider in auto, liability, no-fault and workers compensation claims, Optum Settlement Solutions remains the leader in providing accurate and affordable mandatory insurer reporting, conditional payments resolution and set aside allocations, approval and administration services.
As always, we will continue to update the property and casualty insurance industry with news, trends or additional updates from CMS and the WCRC.


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