Medicare Set-Aside Administration Questions and Answers

The administration of a Medicare Set-Aside and the requirements for proper administration can sometimes be unclear and confusing. Below is a list of frequently asked questions and answers to assist the parties in better understanding this process.

If claimant still has money left in the WCMSA and is no longer being treated for the work injury, can the WCMSA funds be released?

No.  WCMSA funds can only be released upon the death of a claimant and only after the regional office and the BCRC have confirmed that all claims for the WCMSA have been paid. This is the case also if the funds are being professionally administered. The professional administer must also ensure that all outstanding claims from providers are paid before releasing funds to the appropriate party.

Can claimant use the funds in the WCMSA to pay for injury-related Medicare-covered treatment prior to Medicare entitlement? What if claimant loses entitlement to Medicare after the WCMSA is established?

According to Section 17.4.2 of the WCMSA Guide, the WCMSA may be used for injury-related Medicare-covered expenses prior to the claimant becoming a Medicare beneficiary. If the claimant loses his or her entitlement to Medicare after the WCMSA is established, claimant cannot release these funds and they must still be used for injury-related Medicare-covered treatment.

Can claimant use the WCMSA funds to pay for medical treatment outside of the United States?

WCMSA Reference Guide 3.2 Section 17.3 states that “WCMSA funds may only be used to pay for those expenses that would normally be paid by Medicare.” Medicare does not cover payment for treatment outside of the United States except for very limited circumstances i.e. emergency situations.  As such, WCMSA funds cannot be used for this purpose. There may be other funding options available to the parties in these situations.

What Is an annual attestation statement and how is this form completed?

An attestation statement is a record-keeping tool CMS uses to monitor what monies are in your WCMSA account and what has been spent. CMS also monitors if these funds are being used correctly and can ask for a more detailed audit of these funds if questions arise regarding the WCMSA. The WCMSA Reference Guide Section 17.5 provides the following guidance on attestation statements:

Every year, beginning no later than 30 days after the one-year anniversary of settlement, the administrator must sign and send a statement that payments from the WCMSA account were made for Medicare-covered medical expenses and Medicare-covered prescription drug expenses related to the work-related injury, illness, or disease. This annual attestation must be submitted no later than thirty days after the end of each year, beginning one year from the establishment of the WCMSA account. Annual self-attestation should continue through depletion of the WCMSA account.

Annual accounting can be done via the portal or paper copy and sent to CMS at:

NGHP, P.O. Box 138832, Oklahoma City, OK 73113

Can a spouse or other family member be added to the WCMSA account to assist with paying bills?

Yes. All account management rules in administering the WCMSA would still apply.

What happens if claimant has a structured settlement annuity and the funds are temporarily exhausted in a given year?

WCMSA Reference Guide Section 19.3.2 states:

If a structured WCMSA proves to be under-funded for a given period because the funds are exhausted by the claimant’s medical expenses before the period ends, and if CMS receives verification of exhaustion of both the structured amount for the period and any available roll-over funds, then Medicare will pay for additional medical expenses incurred during the period.

How does claimant know how much to pay a provider? Does the claimant still get a discount on medical pricing?

In states that have a Workers’ Compensation Fee Schedule, providers should be paid and should be billing at the fee schedule amount. If claimant has been treating with the provider for the work injury, the provider should be aware of this and should also be told by the claimant or counsel that the parties have settled the claim and all bills should be paid from the WCMSA.

If the WCMSA is being administered professionally, the administrator can work with the provider to reprice bills at the appropriate fee schedule amount and can also work on obtaining discounts on other items in the WCMSA including prescription drugs.

Can the claimant get assistance with the WCMSA administration even if he or she Is self-administering the account?

There is often a misconception that claimant must choose between professional administration or going it alone. However, Bridge Pointe has been offering self-administration support services to claimants as an alternative to professional administration for many years. The purpose of self-administration with support is to enable the claimant to have the freedom of self-administration and still have support with bill repricing, Medicare-coverage questions, attestation statement assistance, discounted treatment opportunities, assistant communicating with providers about the establishment and pricing of the WCMSA and much more.

If the WCMSA is exhausted, who notifies Medicare?

A final accounting needs to be sent to Medicare by the professional administrator (if there is one) or the claimant if they are self-administering the WCMSA funds.

If the WCMSA is exhausted and the claimant is still receiving treatment, who pays for the treatment?

If the claimant is a Medicare beneficiary, Medicare takes over payment and, if not, claimant would have to pay these expenses out of pocket or utilize other healthcare options.