CMS Releases Updated WCMSA User Guide and Self-Administration Toolkit

WCMSA User Guide

Version 2.3 of the Workers’ Compensation Medicare Set-Aside (WCMSA) User Guide was released January 5, 2015. Importantly, language was added regarding hydrocodone compounds schedule change and the deadline for responding to development requests has been extended for cases submitted through the WCMSA Portal.

In Section 9.4.6.2, Pharmacy Guidelines and Conditions, language was added addressing the hydrocodone compound schedule change. The reclassification occurred in October 2014, changing these products from a C-III controlled substance to a C-II controlled substance. This is significant because C-IIs require a new prescription every thirty (30) days or less while C-IIIs only require new prescriptions after five refills or six months, whichever occurs first. Under the C-II regulations, a physician may issue up to three prescriptions in one visit which would allow the patient to receive a ninety (90)-day supply in one office visit. For WCMSAs submitted on or after January 1, 2015, a minimum of 4 healthcare provider visits per year must be allocated when schedule II controlled substances are used, unless the medical records document more frequent provider visits.

Additionally, the amount of time allowed for responding to development requests for cases submitted through the WCMSA portal was extended from ten (10) days to twenty (20) days. Once the time allowed has passed, CMS closes the file and treats the subsequent submission as a new case. See Sections 9.4.1 and 9.5.

Additional changes were made to clarify language found in previous versions. To view the updated WCMSA User Guide in its entirety and a list of all changes, click here.

Self Administration Toolkit

CMS also released a toolkit for the self-administration of Medicare Set-asides as a resource for claimants. The toolkit lays out the process and guidelines of self-administration, from the time the WCMSA account is first established through its exhaustion. It explains who claimants will work with to manage their account, discusses lump sum verses structured settlement accounts and even covers special circumstances, such as when a beneficiary's status changes. The full toolkit can be downloaded here.