CMS Memorandums and Related Materials

  • WCMSA Top Submission Errors and Helpful Hints
    Last Updated 05/20/2013, link to the CMS page here.
  • CDC’s 2012 Life Table
    As of April 1, 2017, CMS will begin referencing CDC’s Life Table 1, V65 N8 for WCMSA life expectancy calculations.
  • Workers Compensation Medicare Set-aside Arrangements (WCMSAs) Reference Guide
    Rev. 2016/4 April COBR-Q1Q2-2016-v2.5.
  • Inclusion of benzodiazepines and barbiturates starting 06.01.2013
    On October 2, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to Part D Sponsors concerning the transition to Part D Coverage of Benzodiazepines and Barbiturates beginning in 2013. Effective June 1, 2013, all  Workers’ Compensation Medicare Set-Aside (WCMSA) proposals submitted to CMS for a review of the adequacy of the proposal amount are to include the pricing of benzodiazepines and barbiturates, where appropriate. Please note that WCMSA cases submitted to CMS  before June 1, 2013, closed due to missing, incomplete and/or inadequate supporting documentation (or any  other reason), and subsequently re-opened after June 1, 2013, will also be subject to a review that includes the pricing of benzodiazepines and barbiturates.
  • Decision Memo for Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain (CAG-00429N)
    TENS is not reasonable and necessary for the treatment of CLBP under section 1862(a)(1)(A) of the Social Security Act.
  • Medicare Secondary Payer Fact Sheet for Provider, Physician, and Other Supplier Billing Staff
    The purpose of this fact sheet is to provide a general overview of the MSP provisions for individuals involved in the admission and billing procedures for health care providers, physicians, and other suppliers.
  • Medicare Secondary Payment Subrogation Rights
    The purpose of this memorandum is to summarize and convey support for regulations giving Medicare Advantage organizations (MAOs) and Prescription Drug Plan (PDP) sponsors the right, under existing Federal law, to collect for services for which Medicare is not the primary payer.
  • CMS Revised Timeline for TPOC 09.30.2011
    Revised Implementation Timeline for Certain Liability Insurance (Including Self-Insurance) Total Payment Obligation to the Claimant (TPOC) Settlements, Judgments, Awards or Other Payments
  • CMS Memorandum 09.29.2011
    The purpose of this memorandum is to provide information regarding proposed Liability Medicare Set-Aside Arrangement (LMSA) amounts related to liability insurance (including self-insurance) settlements, judgments, awards, or other payments (“settlements”).
  • CMS Texas Regional Handout 05.25.2011
    Memo from the CMS’ Texas Regional office on Liability MSAs
  • CMS Memorandum 05.11.2011
    The purpose of this memorandum is to reiterate guidance provided in the Centers for Medicare & Medicaid Services’ (CMS’) July 23, 2001, July 11, 2005, and April 25, 2006 procedure memoranda regarding CMS’ Workers’ Compensation Medicare Set-aside Agreement (WCMSA) proposal review thresholds, which can be found on CMS’ Web site at: http://www.cms.gov/WorkersCompAgencyServices.
  • CMS Revised Timeline for TPOC 11.09.2010
    I. Revised Implementation Timeline for TPOC Liability Insurance (Including Self-Insurance) Settlements, Judgments, Awards or Other PaymentsII. Extension of Current Dollar Thresholds for Liability Insurance (Including Self-Insurance) and Workers’ Compensation
  • CMS Rated Age Clarification 06.08.2010
    This memorandum clarifies the guidance provided in the Centers for Medicare & Medicaid Services (CMS) May 14, 2010 procedure memorandum regarding the Rated Age (RA) language to be included on WCMSA proposals.
  • CMS Direct Data Entry (DDE) Option 05.25.2010
    This ALERT provides information about a new Direct Data Entry (DDE) option for reporting liability insurance (including self-insurance), no-fault insurance, and workers’ compensation (collectively referred to as Non-Group Health Plan or NGHP) information mandated by Section 111 of the MMSEA of 2007.
  • CMS Memorandum 05.14.2010
    The purpose of this memorandum is to clarify guidance provided in the Centers for Medicare & Medicaid Services’ (CMS’) April 3, 2009 and July 1, 2009 procedure memoranda regarding prescription drugs administered to Medicare beneficiaries for off-label and/or unlabeled outpatient uses and whether these drugs are considered covered by Medicare Part D and, therefore, appropriately included in a Medicare Workers’ Compensation Set-aside Agreement (WCMSA) proposal. Also, this memorandum changes the Rated Age (RA) language to be included in WCMSAs, as detailed in the August 25, 2008 procedure memorandum.
  • 270/271 Companion Guide for Non-GHP Entities 02.01.2010
    270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting Non-GHP Entities
  • CMS Alert 08.24.2009
    Compliance Guidance Regarding Obtaining Individual HICNs and/or SSNs for Non-Group Health Plan (NGHP) Reporting Under 42 U.S.C. 1395y(b)(8)
  • CMS Memorandum 06.01.2009 CMS Prescription Drug Set-Aside Guidance for Submitters
    Effective: June 1, 2009
  • CMS Memorandum 04.03.2009
    The purpose of this memorandum is to set forth the Centers for Medicare & Medicaid Services’ (CMS’) procedures regarding the methodology of pricing future prescription drug treatment costs/expenses in Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) proposals.
  • CMS Alert 03.20.2009
    This alert addresses the following issues:
    Extended Permissible Testing Period
    Interim Reporting Threshold
    Registration Information
    Error in the Field Descriptions on the TIN Reference File in the MMSEA Section 111 User Guide for Liability Insurance (Including Self-Insurance), No-Fault Insurance and WorkerCompensation (“User Guide”)
    HEW Software .
  • CMS Memorandum 08.25.2008
    The purpose of this memorandum is to include policy regarding the pricing of Implantable Devices and to replace the policies regarding “Beneficiaries that Request Termination of a Workers’ Compensation Medicare Set-Aside (WCMSA) Account” in Question and Answer 10 of the July 11, 2005 Associate Regional Administrator memorandum.
  • CMS Memorandum 05.20.2008
    The purpose of this memorandum is to include policy regarding the exclusive use of the Centers for Disease Control (CDC) Table 1 (All American Table) when determining life expectancy in Workers’ Compensation Medicare Set-Asides (WCMSA) proposals. The Centers for Medicare & Medicaid Services (CMS) will only accept life expectancies obtained from the CDC Table 1, “Life table for the total population.”
  • CMS Memorandum 07.24.2006
    This memorandum supersedes the Part D and Workers’ Compensation Medicare Set-aside Arrangements (WCMSA) memorandum that was published on December 30, 2005. It includes policy regarding the inclusion of future prescription drug treatment costs/expenses in WCMSAs.
  • CMS Memorandum 04.25.2006
    The purpose of this memorandum is to replace Q/A #2 of the July 11, 2005 Memorandum with regard to the Centers for Medicare & Medicaid Services’ (CMS’) low dollar WCMSA threshold for Medicare beneficiaries. Effective with the issuance of this memorandum, CMS will only review new WCMSA proposals for Medicare beneficiaries where the total settlement amount is greater than $25,000.00. The CMS wishes to stress that this is a CMS workload review threshold and not a substantive dollar or “safe harbor” threshold. Medicare beneficiaries must still consider Medicare’s interests in all WC cases and ensure that Medicare is secondary to WC in such cases.
  • CMS Memorandum 12.30.2005
    Beginning January 1, 2006, Medicare will begin its Part D prescription drug coverage as a result of the implementation of the Medicare Modernization Act of 2003 (MMA). This memorandum includes policy regarding the inclusion of prescription drugs that Medicare will cover as of January 1, 2006, in Workers’ Compensation Medicare Set-aside Arrangements (WCMSAs).
  • CMS Memorandum 07.11.2005
    1. Clarification of WCMSA Non-beneficiary Threshold;2. Low Dollar Threshold for Medicare Beneficiaries;3. Use of WC Settlement Funds Prior to Medicare Entitlement;4. Avoiding the Continuation of Indemnity Payments While Waiting for CMS to Review a WC Medicare Set-aside Arrangement (WCMSA);5. Settlement of WC Medical Expenses Prior to Submission to CMS;6. Treatment of Taxable Interest Income Earned on a WCMSA;7. Sample Submission of a WCMSA;8. Group Health Plan (GHP) Insurance and Veteran’s Administration (VA) Coverage;9. Loss of Medicare Entitlement after CMS Approval of a WCMSA;10. Beneficiaries that Request Termination of WCMSA Funds;11. Compromising of Future Medical Expenses;12. Additional Information Submission after WCMSA Case is Closed;13. Effect of WCMSA on Medicaid Eligibility;14. CMS Recognition of State Specific Statutes;15. Transfer Mechanism
  • CMS Memorandum 10.15.2004
    Medicare Secondary Payer (MSP) — Workers’ Compensation (WC)
    Additional Frequently Asked Questions:1) Use of WC Fee Schedule vs. Full Actual Charges for WC Medicare Set-aside Arrangement (WCMSA);2) Self-administration of a WCMSA;3) Up-front Settlement of Future Medicals vs. WCMSA;4) Inflation Adjustment/Discount to Present Value;5) Structured WCMSAs;6) WC Claim Resolution Where Medicals Remain Open.
  • CMS Memorandum 05.07.2004
    The purpose of this All Regional Administrators memorandum is to replace the policy that was outlined in the answers to questions in the All Associate Regional Administrators (ARA) memorandum concerning Workers’ Compensation Commutation of Future Benefits (issued on July 23, 2001, attached) and in the answer to question seven from the April 21, 2003 Frequently Asked Questions.
  • CMS FAQ 05.23.2003
    Medicare Secondary Payer — Workers’ Compensation (WC) Additional Frequently Asked Questions.
  • CMS Memorandum 04.21.2003
    Medicare Secondary Payer — Workers’ Compensation (WC) Frequently Asked Questions
  • CMS Memorandum 07.23.2001
    Workers’ Compensation: Commutation of Future Benefits