Medicare Announces Enhanced Data Sharing of Worker’s Compensation Medicare Set Aside Information with Part D Plans Highlighting the Importance of Professional Administration
On November 19, 2025, the Centers for Medicare & Medicaid Services (“CMS”) issued a memorandum announcing that in February 2026, the agency would begin providing Medicare Part D plans with certain prescription drug information and “additional data elements” which those plans may use to improve coordination of benefits in relation to workers’ compensation Medicare Set Asides (“MSAs”). The memo can be accessed on this page and is titled: Coordination of Benefits-Other Health Insurance (COB-OHI) Companion File to Include Data on Workers’ Compensation Medicare Set-Aside (WCMSA) Arrangements. This new data sharing highlights the critical importance of post-settlement considerations and the value of professional administration.
The A, B, Cs… and Ds of Medicare: Quick Primer on Medicare Coverage
Established in 1965, Medicare provides federal health insurance for individuals aged 65 and older, as well as younger people with qualifying disabilities. Medicare Part A covers inpatient hospital care, while Part B covers outpatient services. Together, Parts A and B are commonly referred to as “traditional Medicare.”
Because traditional Medicare offers limited coverage, many beneficiaries choose Medicare Advantage, also known as Medicare Part C. Introduced in 1997, Part C plans are administered by private insurers such as UnitedHealthcare, Humana, Blue Cross Blue Shield, and Aetna. As of 2025, nearly 35 million beneficiaries, approximately 54% of those eligible for Medicare, are enrolled in a Medicare Part C Plan – otherwise known as Medicare Advantage. The key advantage (deliberate pun) of Part C is that it often includes benefits not covered by traditional Medicare, such as vision, hearing, and dental care.
In 2003, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) introduced Medicare Part D, which provides prescription drug coverage. Like Part C, Part D plans are offered through private insurance companies. As of 2025, almost 55 million people are enrolled in a Medicare Part D plan.
Increased Attention on MSAs and Coordination with Part C & D Plans
Guidance around MSAs in relation to Part C & D coverage has been mounting. On August 1, 2024, CMS issued version 4.1 of the Workers’ Compensation Medicare Set Aside (“WCMSA”) Reference Guide (currently on version 4.4). In version 4.1, section 4.1.3 was added. The takeaways are as follows:
- CMS notifies Part C and D plan sponsors that a WCMSA has been approved and instructs plan sponsors to conduct Medicare Secondary Payer (MSP) investigations.
- However, CMS does not relay WCMSA details to plan sponsors. Instead, CMS instructs plan sponsors to seek WCMSA coverage details from the WCMSA administrator as part of the plan sponsor’s investigation.
- When possible, Part C and D plan sponsors are required to avoid paying for expenses that should be covered by a WCMSA.
- The administrator must provide details concerning treatments and medications used exclusively to treat a related illness or injury to the plan sponsor so the sponsor may avoid making primary payment in the future.
See Sec. 4.1.3 of the WCMSA Reference Guide.
On August 1, 2024, CMS also issued an updated the WCMSA Self-Administration Toolkit (currently on version 1.7 and now titled Self-Administration and You: A Beneficiary Toolkit for Workers’ Compensation Medicare Set-Aside Arrangements). In the August 2024 update the pertinent revised language in Sec. 4 is as follows:
- You must tell your insurance plan sponsor any details concerning treatments and medications used exclusively to treat a related illness or injury, so they can avoid making primary payment in the future.
- CMS requires your plan to contact you or the administrator of your MSA to find out which expenses are covered by your MSA.
- The plan [Part C / D Plan] must avoid paying for expenses that are included in the MSA.
- The plan has a responsibility to recover any payments it made that should have been paid by the MSA.
- If you do not respond to your plan’s investigation efforts, your coverage may be delayed or cancelled.
- If you are enrolled in a Medicare Advantage or prescription drug plan, please contact your plan to discuss your MSA, if you have not already done so.
See Sec. 4 of the Self-Administration and You: A Beneficiary Toolkit for WCMSA Arrangements.
Sec. 8 of the Toolkit also added the following related to attestation reporting of MSA information to Medicare in relation to Part C/D:
- This attestation is required annually, even if you are enrolled in a Medicare Advantage or prescription drug plan. You should also contact your plan to discuss any changes in medication or treatment that should be covered by the WCMSA.
The above policy guidance places a sharp focus on the importance of post-settlement MSA administration as it relates to Medicare Part C & D coverage.
MSA Data Sharing Visibility Increases with Part D Plans in 2026
Attention around Part D (and C) has been increasing and will continue to do so in 2026. The Memo released by CMS on November 19, 2025 indicates that starting in February 2026, Medicare will provide Part D plans with specific prescription drug information and additional data points which will assist in coordinating benefits with MSAs.
Specifically, the memo notes that, “CMS will provide Part D sponsors with WCMSA related prescription drug information through the new Medicare Beneficiary Database Other Health Insurance Monthly (MBDOHIMO) file, to be transmitted as a companion file to the
Coordination of Benefits-Other Health Insurance (COB-OHI) file.” The memo goes on to clarify that, “[t]he newly provided data will include the Workers’ Compensation Case Control Number and up to 12 NDCs for each applicable WCMSA.” The Case Control Number is the unique identifier for voluntarily submitted MSAs, and NDC stands for National Drug Code, which is a universal product identifier that is used for identification, billing and collaterally for MSA pricing purposes.
The enhanced data sharing procedures appear to be associated with MSAs which are reviewed and approved through CMS’ voluntarily submission process and it is unknown whether the agency will implement similar Part D data-sharing procedures for non-submitted or non-threshold MSAs. It is important to note that no specific drug information (i.e., NDC codes) are captured in the Section 111 reporting fields related to workers’ compensation settlements involving MSAs.
Following receipt of MSA information, Medicare directs Part D plans to continue to follow procedures outlined in Chapter 14, Sec. 50.12, of the Medicare Prescription Drug Benefit Manual (“pay and chase”) or “…adopt the alternative method of MSP adjudication described
in this memorandum.”
Under this new alternative method, “…instead of making conditional primary payments while awaiting coordination with a WCMSA administrator, for those enrollees with NDCs provided via the MBDOHIMO file sponsors may utilize the information provided to introduce prior authorization requirements and implement beneficiary-level point-of-sale edits for the drugs identified for that enrollee’s WCMSA.” A point-of-sale-edit is a real-time claims check that occurs while the pharmacist is processing a prescription. It’s a control mechanism to ensure payment is made (or not) appropriately. Part D plans who do not perform point-of-sale edits are directed to “pay and chase.”
Importantly, Medicare expects Part D plans to “…accept an attestation by the WCMSA administrator or enrollee that the requested drug is not related to the workers’ compensation injury as sufficient evidence for Part D to serve as the primary payer and resolve the edit.” Moreover, CMS expects Part D plans to remove any point-of-sale edit when depletion or exhaustion of the MSA occurs.
CMS Part D Memo Highlights the Importance of Professional Administration
In summary, the new data-sharing procedures reinforce CMS’ focus on post-settlement coordination of benefits with MSAs. Part D plans may now appropriately deny payment for prescription drugs which should be paid for from the MSA.
To avoid potential denials, it will be critical for injured individuals to properly administer their MSA – which includes accurate and timely reporting of attestation information. For this reason, as CMS does, it is highly recommended that injured individuals utilize a professional administrator. Couple the above changes with Sec. 111 reporting requirements for MSAs designed to provide Medicare with greater post-settlement visibility, it’s more important now than ever to set a settlement up for success by mandating professional administration.
Ametros will be following the implementation of these new data-sharing policies closely. To learn more about these changes and how to safeguard your settlement, protect injured workers post-settlement and avoid risk and exposure, please contact us at 877-983-9564 or e-mail us at marketing@ametros.com.
