FROM THE DESK OF MANAGING PARTNER SARAH THOMAS
Dear Valued Clients,
Jones Jones is aware the Centers for Medicare & Medicaid Services (CMS) will be implementing changes to impacting Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) in the first half of 2025. These changes are based on a review of the current WCMSA guidance and feedback from the WCMSA community.
The changes being implemented in 2025 are as follows:
- Expanded Section 111 Reporting Requirements: Effective April 4, 2025, CMS has begun requiring Section 111 reporting for WCMSAs involving Medicare beneficiaries. If a claimant is a Medicare beneficiary, details of the settlement must be reported to CMS, including on claims involving a $0 WCMSA, and settlements below $25k.
- Amended Reviews: Effective April 7, 2025, amended review requests will be allowed at any time after a WCMSA case is approved. This is a change from the prior amended review request process which requires a one-year waiting period after a WCMSA case has been approved.
- Zero-Dollar Set-Asides: Effective July 17, 2025, CMS will no longer accept or review WCMSA proposals with a zero-dollar allocation. Entities should still consider the parameters available in the WCMSA Reference Guide to determine whether a zero-dollar WCMSA allocation is appropriate and should maintain documentation to support that allocation.
- Updated WCMSA Reference Guide: As of January 16, 2025, the Update Workers’ Compensation Medicare Set Aside Reference Guide (WCMSA Reference Guide version 4.2) is now available: https://www.cms.gov/medicare/coordination-benefits-recovery/workers-comp-set-aside-arrangements.
What This Means for our Clients
The upcoming changes will have an impact for insurance carriers and their insureds. The changes outlined above will have the following effect:
- CMS will have unprecedented visibility into the facts of a full and final settlement involving a Medicare beneficiary, including on claims that do not meet the $25k threshold for CMS approval.
- If an individual’s medical situation has changed, or if they have had a significant surgical procedure that was originally included by the CMS, parties can now apply for amended review as soon as the case is approved.
- If CMS approved a medical set aside that was otherwise untenable, an insurance carrier can now submit for amended review to get the set aside reduced more quickly.
The changes outlined above will reduce delays in securing final settlements and will facilitate more settlements in general, increasing the potential for cost savings and positive outcomes.
Steps Jones Jones is Taking
At Jones Jones, we work to communicate all changes from legislative and government administration bodies that may impact our clients. We are prepared to take action in response to ensure compliance and cost-savings to our clients.
As a result of the upcoming WCMSA changes, a team of Jones Jones’ attorneys is prepared to:
- Work with clients to update their settlement protocols to reflect the new Section 111 Reporting Requirements.
- Assist clients who would like to consider amended review of a medical set aside that previously obtained CMS approval.
- Review any medical set asides for potential opportunities for cost savings.
We can confer and provide recommendations regarding the new reporting requirements, or the possibility of a WCMSA amended review request, and take appropriate measures. Our goal at Jones Jones is to strive toward excellence each day with you, our clients. Any client who would like to confer regarding the above-mentioned updates should contact clientservices@jonesjonesllc.com.
