Key Changes to the Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide Version 4.3
On April 7, 2025, the Centers for Medicare & Medicaid Services (CMS) released version 4.3 of the Workers' Compensation Medicare Set Aside Reference Guide (WCMSA). This update includes several important changes that reflect CMS’s continued efforts to improve clarity, transparency, and oversight. Key revisions include updates to the amended review process, clarification on the change of submitter, notice of Settlement Received Letter added, and enhanced communication of WCMSA details directly to injured workers. In addition, on April 4, 2025, CMS also updated the WCMSA Self-Administration toolkit to Version 1.7. Together, these changes reflect CMS’ significant step in ensuring proper professional administration and compliance moving forward.
CMS made it clear: they will now share WCMSA details directly with the injured worker including the approved amount, associated injury codes, and the rules for using those funds in place of Medicare. The WCMSA visibility created by the April 4, 2025 TPOC changes makes the proper administration of WCMSA funds more critical than ever. CMS already highly recommends the use of professional administration like Ametros, and this latest move reinforces just how essential that guidance has become.
Three Key Updates from WCMSA Reference Guide Version 4.3
- Notice of Settlement Received Letter: To support Medicare set-aside reporting requirements, the Notice of Settlement Received letter has been added to this guide (Appendix 5).
- Amended Review Process: The one-year wait period for amended reviews has been removed (Section 16.3).
- Change of Submitter: The guide has been updated to clarify CMS’ policies around change of submitter (Sections 16.3 and 19.4)
Notice of Settlement Received Letter
The CMS Notice of Settlement Received Letter (Appendix 5) advises the injured worker (beneficiary) that CMS has received a Notice of Settlement that includes an amount designated for a WCMSA. They advise that this information will assist CMS in making appropriate coordination of benefit decisions. Additionally, CMS will update its systems to indicate that the WCMSA will be utilized to cover related items and services.
The letter also provides a high-level summary of self-administration requirements and provides a link to the self-administration toolkit. Importantly, the letter also includes a warning of some potential consequences. Any Medicare payments that should have been covered by the workers’ compensation settlement, judgment, award, or other payment must be repaid to Medicare.
CMS has also clarified that the Notice of Settlement Received Letter is now sent directly to the Injured Worker (Beneficiary). This letter outlines the requirements for proper administration of WCMSA funds. Previously Medicare only provided this information as part of the WCMSA approval packet which was typically just a few pages included when a MSA was formally submitted. If no submission was made, the injured worker received nothing. This new step marks a significant change: CMS is expanding its communication efforts to reach All Medicare beneficiaries involved in a settlement, even when the WCMSA was not submitted. As a result, the injured workers will now be directly informed of their responsibilities and the consequences of non-compliance.
Quick Highlights from Notice of Settlement Received Letter
- CMS makes it clear that payment for future medical treatment is independent of any determination regarding MSP recovery rights for conditional payments Medicare made for related items and services before the date of the settlement, judgement, award or other payment.
- They indicate that Medicare maintains the right to recover (or take back) Medicare payments made related to any WC settlement, judgement, award or other payment.
- Medicare continues to improve their enforcement of proper coordination of benefits with Section 111 Reporting.
- Parties that choose not to voluntarily submit WCMSA’s, will now be captured in CMS systems for greater coordination of benefits to protect the Medicare fund. Should doctor’s try and bill Medicare for services covered under the WCMSA, they will be denied, unless the beneficiary can demonstrate the WCMSA was adequate, and the funds were properly exhausted.
- If beneficiaries choose to self-administer, they should be well informed of their responsibilities and issues that may arise.
- Injured worker attorneys should educate their clients on the intent of the WCMSA, submission process, and associated administration as part of consent to release notes.
In Section 16.3, there have been two changes:
Amended Review Process
The previous requirement that an amended review could only be submitted at least 12 months after the original approval has been removed. This change reflects updated guidance indicating that parties no longer need to wait one year to request an amended review, provided all other criteria are met.
Change of Submitter
The second update includes new language that states “A change of submitter alone is not sufficient grounds to require an amended review. For the requirements to change a submitter, see Section 19.4.” Additional updates to this section clarify CMS policies regarding the change of submitter process.
Self-Administration Toolkit Update (Version 1.7).
On April 4, 2025, CMS released Version 1.7 of the WCMSA Self-Administration Toolkit. This update introduced a few notable structural and content changes. One of the most significant updates is the removal of the section on inheritance, which was previously included in Version 1.6. Additionally, CMS swapped the order of Section 2 and 3.
Conclusion
These recent updates from CMS signal a continued push for greater transparency, accountability, and education around WCMSA administration. With expanded communication to beneficiaries and updated guidance tools, proper compliance is no longer just recommended- it’s essential, and using a professional administrator like Ametros can help ensure funds are managed correctly and consistently with CMS expectations.
If you have any questions, please reach out to us. If you have a future medical case that may require Ametros’ professional administration expertise, please provide a few details with our referral form.
