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Home > Archives for News

CMS Updates Pertaining to WCMSAs and Section 111 Reporting

04.22.2025

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. 

 


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Filed Under: Blog, Education, News

NY Governor Signs Amendment with Guidance on Interpreting Work-Related Stress in New Mental Injury Legislation Allowing New Yorkers to Apply for Workers’ Compensation

03.26.2025

The New York State Workers’ Compensation Board has provided an update on the December 2024 Mental injury legislation, providing clarity for employers, insurers, and legal counsel alike on the interpretation of extraordinary work-related stress. For context, on December 6, 2024, Governor Hochul signed legislation amending Section 10 of the Workers’ Compensation Law (WCL) with respect to claims for mental injuries resulting from work-related stress, subject to a chapter amendment agreed to by the Legislature and the Governor (Laws of New York, 2024, Chapter 546, Approval Memorandum 21 [enacting S6635/A5745]).

On February 14, 2025, the Governor signed a chapter amendment (Laws of New York, 2025, Chapter 79 [enacting S755/L1677]). The amendment says that covered employees must demonstrate that the mental disorder arose out of extraordinary work-related stress attributable to a distinct work-related event or events directly related to the employment and occurring during the performance of the employee’s job duties.

The new amendment will take effect June 4, 2025.

What this Means for Employers and Insurers

The key in this new amendment is the word extraordinary. Defining what constitutes extraordinary will come down to each case or judge and cannot be definitively determined until litigation begins in June. The same can be said for the word distinct when referring to distinct work-related events or an event. While the definition and impact of these terms won’t be clarified until June, there are other impacts that these amendments bring, including:

  • The amendments to WCL § 10 in S6635/A5745 were superseded by the chapter amendment signed on February 14, 2025 (S755/L1677) and are no longer in effect.
  • The amendments to WCL § 10 in S755/L1677 that go into effect on June 4, 2025, will apply to all pending claims, regardless of the date of accident.
  • Prior to June 4, 2025, pending claims will be decided based on existing law.

Of note, a new paragraph (c) will be added to subdivision (3) of WCL § 10, providing:

(c) The board may not disallow a claim by a covered employee upon a factual finding that the stress was not greater than that which usually occurs in the normal work environment where a claim for post-traumatic stress disorder (PTSD), acute stress disorder or major depressive disorder resulting from work-related stress is filed upon submission of medical evidence based on the criteria contained in the version of the Diagnostic and Statistical Manual of Mental Disorders in effect on the date of accident, or as otherwise adopted by the board, provided that such adoption shall be no more stringent than the current or immediately preceding version of the Diagnostic and Statistical Manual of Mental Disorders. Such covered employee must demonstrate that such disorder arose out of extraordinary work-related stress attributable to a distinct work-related event or events directly related to the employment and occurring during the performance of the employee’s job duties.

What Jones Jones is Doing

Jones Jones will continue to monitor New York State Workers’ Compensation Law for additional updates, as well as work closely with legislators, judges, clients and others to clarify how the term work-related stress is now interpreted. We will also continue to closely watch any upcoming mental injury workers’ compensation cases or decisions made on mental health injuries to prepare for the potential influx of newly filed claims.

For more information on this new legislation, please visit the New York State website. If you have questions about how this new legislation may impact you, or if you have a mental injury connected to extraordinary work-related stress claim, please contact us at clientservices@jonesjonesllc.com

The legislation signed by New York Governor @Kathy Hochul on Dec. 6 and a February 14 amendment are set to take effect June 4, 2025, amending Section 10 of the Workers’ Compensation Law (WCL) with respect to claims for mental injuries resulting from work-related stress. Jones Jones will continue to monitor the NYSWCB for additional updates and prepare to take necessary action for the potential influx of newly filed claims.

 


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Filed Under: Blog, Education, News

Jones Jones Expands New Jersey Team with Workers’ Comp Industry Veteran

02.14.2025

Jones Jones LLC is pleased to announce the addition of James Koblin to the New Jersey team. James will join Supervising Partner Christine Diana and Operations Partner and fourth generation Jones family attorney Kristina Jones among others in the New Jersey office.

 

“I met James in the Jersey City Workers’ Compensation Court during my first year of practice when we were on opposing sides of a case. His tenacity and skill impressed me then, and he continues to impress me today,” said Supervising Partner Christine Diana. “New to the practice, it feels like James has always been a part of the team. His keen sense of detail and proficiency in identifying issues of concern among other impressive traits, make him a great asset to the team. We are glad to have him aboard”.

 

In his role as Associate for the New Jersey team, James will handle claims from inception to resolution, attending hearings across the state in New Jersey Workers’ Compensation Court. His previous work as a petitioner attorney will bring our team fresh perspective from the other side.

 

With almost 30 years of experience in the New Jersey Workers’ Compensation space, James has strong relationships with the bench, respondent’s counsel and has spent considerable time handling claims across the state. He has resolved thousands of workers’ compensation claims to settlement or completion, including fully litigated motions, judgments, orders for total disability and Section 20 settlements. James is also certified in workers’ compensation by the Supreme Court of New Jersey.

 

For more information on James and the rest of the Jones Jones team, please visit https://jonesjonesllc.com/.

 


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Filed Under: Blog, News

New Practices Areas and Service Offerings

02.05.2025

Dear Valued Clients,

As many of you know, Jones Jones has litigated workers’ compensation cases in the aviation and retail spaces for years. We have successfully settled a number of cases and secured positive outcomes in others in both sectors. As these types of cases continue to manifest, we recognized a need for established practices in these spaces to best address the needs of our clients in this space and to further refine our expertise and build on our track record in both sectors.

As of February 5th, 2024, we are pleased to announce the launch of the new Aviation and Retail practices at Jones Jones LLC. Our aim is to expand our service offerings while continuing to innovate and provide excellence as part of our core tenets.

The Aviation Practice

The Aviation Practice will span both New York and New Jersey, led by Partner Simeon Stamm. The practice will manage and oversee claims handling and litigation, specializing in training teams in best practices related to workers’ compensation litigation in the aviation space. The practice will have a special focus on industry trends and emerging risks and will approach all claims through both a workers’ compensation and general liability lens.

The Retail Practice

The Retail Practice will also span both New York and New Jersey, led by Partner Yvie Cherenfant. The practice will also manage and oversee claims handling and litigation and will specialize in workers’ compensation litigation for brick-and-mortar retail businesses, including but not limited to:

    • Grocery Stores
    • Convenience Stores
    • Big Box Retailers
    • E-Commerce Sites
    • And more

The practice will have a special focus on effective settlement of active cases and industry specific risks and will approach all claims with a focus on workers’ compensation and general liability matters.

Both practice areas will be supported by me and Executive Partner Matthew Jones in New York and Operations Partner Kristina Jones in New Jersey. Both are fourth generation Jones family attorneys.

For more information about Jones Jones LLC or to inquire about the Aviation or Retail practices, please visit https://jonesjonesllc.com/ or contact us at clientservices@jonesjonesllc.com.

Signed,
Sarah Thomas
Managing Partner
Jones Jones LLC

 


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Filed Under: Blog, Education, News

Increase in Proposed Decisions from The Board

12.30.2024

FROM THE DESK OF MANAGING PARTNER SARAH THOMAS

 

Dear Valued Clients,

 

Jones Jones is aware that with the most recent updates from the New York Workers’ Compensation Board (the Board), including new employee/employer identification guidance, new claim conciliation procedures for additional sites of injury and consequential injuries, and expanded desk reviews for Section 32 waiver agreements, there will be an increase in proposed decisions from the Board.

 

What This Means for Insurers

Proposed decisions from the Board have the same weight as decisions from a Law Judge and must be thoroughly evaluated. After a proposed decision is investigated, action will oftentimes need to be taken. Such actions include, but are not limited to:

  • Review of a medical file
  • Request for testimony of the claimant or a lay witness
  • Request for cross-examination of a doctor
  • Objection to the board decision.

These actions, and others are necessary and important for ensuring you receive the best outcome possible, regardless of the proposed decision. Jones Jones intends to continue partnering with our clients to ensure they are properly supported in the wake of these changes.

 

Steps Jones Jones is Taking

A team of Jones Jones attorneys is prepared to review each proposed decision in detail and act on those that might impact a client’s case. Proposed decisions could influence an increase in body part establishment, prompt issue awards such as schedule loss of use, or even act as the catalyst to begin permanency litigation. At Jones Jones, we will do all we can to ensure there are no negative effects on your case due to proposed decisions.

 

Any client who receives a proposed decision from the Board should forward the file to clientservices@jonesjonesllc.com where we will review the decision on your behalf and take appropriate measures. Our goal at Jones Jones is to strive toward excellence each day with you, our clients. For more information regarding recent updates from the Board, please visit our blog page. For any questions regarding these updates or if you have a proposed decision from the Board for review, please email clientservices@jonesjonesllc.com


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Filed Under: Blog, Education, News

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