CMS Warns Against Using ‘Non-Submit’ and ‘Evidence-Based’ Medicare Set-Asides

The Centers for Medicare & Medicaid Services (CMS) has updated its Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide (Reference Guide).

The latest version, Version 3.5, was published Jan. 10, 2022. The Reference Guide was updated to clarify the use of non-CMS-approved products to address future medical care.

Medicare is a secondary payor — that is, it does not have primary payment responsibility on behalf of its beneficiaries when another entity is responsible for paying for medical care before Medicare.

Workers’ compensation is a primary payor for work-related illnesses or injuries. So Medicare will not pay for a beneficiary’s medical expenses when payment has been made or can reasonably be expected to be made by a workers’ compensation insurer.

Medicare’s interests must be considered and protected in any workers’ compensation settlement of future medical care involving a Medicare beneficiary or someone who is reasonably expected to enroll in Medicare within 30 months of settlement.