Breaking Down Medicare’s Updated Guides & Toolkits  

The Medicare Secondary Payer (MSP) Act is federal law that intersects with workers’ compensation (and other non-group health insurance types) and is statutorily and regulatorily based. However, many of the mechanisms that effectuate and enforce the MSP exist in policy that’s found in agency-published reference guides, user guides, toolkits and other documentation.  

Sometimes updates to these documents happen sporadically, but other times – like recently – they happen all at once. The Centers for Medicare & Medicaid Services (CMS) released several updates this past Monday to key MSP policy documents. On April 7, 2025, CMS issued the following: 

• Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide, v4.3 

• WCMSA Self-Administration Toolkit, v1.7 

• Non-Group Health Plan (NGHP) Sec. 111 User Guide, v.8.0 

• The presentation from the March 27, 2025 webinar for Beneficiary Representatives and  Medicare Secondary Payer (MSP) 

Each of the above documents and their changes will be addressed in turn below.   

Workers’ Compensation Medicare Set Aside (WCMSA) Reference Guide 

This reference guide is published by CMS and provides detailed information, policies, and guidance on Medicare Set Asides (MSAs) – including their preparation, voluntary submission / review process, and their administration. “The intent of this reference guide is to consolidate and supplant all historical memoranda in a single point of reference.” See Sec. 1.0 of the WCMSA Reference Guide. The following are updates to v4.2 of this new guide.  

Notice of Settlement Received Letter  

There were several additions to this guide. Most notably, a form letter in Appendix 5 titled Notice of Settlement Letter Received was added. This letter coincides with recent changes to Sec. 111 reporting around the requirement for submission of certain MSA data points associated with workers’ compensation settlements. This letter will be issued to a beneficiary following CMS’ notice of a settlement involving an MSA / reporting via Sec. 111 of the same.  

The new letter begins by indicating CMS has received notice of settlement that includes an MSA, and that the information collected will be used for coordination of benefits purposes. It continues by outlining guidelines for properly administering the funds and the annual submission of MSA attestation information (proof to Medicare that the funds were spent properly). This letter and the recent reporting changes continue to emphasize the importance of post-settlement MSA administration.  

Amended Review Process Change Codified in the Reference Guide  

While this policy change had already been announced, it wasn’t until this version of the Reference Guide, that it was formally codified in the guide. As reported previously, on January 21, 2025, CMS updated its policy to alter the Amended Review process by eliminating the one-year waiting period (from the time of the initial MSA decision). If the parties obtain a counter-higher following the voluntary submission of a workers’ compensation MSA, as of April 7, 2025, they no longer must wait a year to avail themselves to the Amended Review process. Effectively, Amended Review allows for a one-time new MSA submission, assuming the requisite criteria are met. See detailed article here on the Amended Review process and Sec. 16.3 of the WCMSA Reference Guide.  

CMS Policies Around Change of Submitter Updated  

The new guide provides guidance around CMS’ policies with respect to change of submitter. A change of submitter occurs when the parties to a case choose to have a different underlying entity take over or re-submit the MSA proposal.  

With respect to the Amended Review process, in Sec. 16.3, CMS indicates a change of the submitter alone is not grounds to allow for an amended review submission. 

In Sec. 19.4 of the guide, CMS provides the following clarification and guidance relative to the change of submitter entity:  

• Written release from services by the current submitter 

• New signed Consent to Release (CTR) form (by the beneficiary / injured party) authorizing the new submitter 

• Submitter changes will not be accepted after the settlement and, again, does not constitute a reason for re-review or amended review 

• CMS notes it will not provide copies of existing documentation to the new submitter and that any documentation must be obtained from the current submitter or claims payer  

WCMSA Self-Administration Toolkit 

This guide, v1.7, has been rebranded and titled as “Self-Administration and You: A Beneficiary Toolkit for Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs)”. There have been some visual, formatting and minor content updates and changes to this document. Notably, Sec. 10 on inheritance was eliminated from this new version – a section which also included guidance on holding the account open for 12 months after the date of the beneficiary’s death, to provide time for lingering bills (as providers can bill up to 12 months after the date of service).   

Overall, this updated guide appears to be geared more towards a beneficiaries and their representatives and the format and branding align with the companion NGHP MSP Beneficiary Reference Guide.  

Webinar Presentation for Beneficiary Representatives and Medicare Secondary Payer (MSP) 

Speaking of beneficiaries and their representatives, CMS released the presentation from their recent webinar held on March 27, 2025. That webinar provided foundational information on MSP concepts for Medicare beneficiaries and their representatives. The agency is making efforts to engage with this stakeholder segment of the community.  

Sec. 111 NGHP User Guide  

The Non-Group Health Plan (NGHP) Sec. 111 User Guide is a multi-chapter guide which contains information and instructions for insurance carriers and self-insured entities – Responsible Reporting Entities (RREs) – and their reporting agents, on Sec. 111 reporting. It is available here. The following are noted changes in version 8.0.  

Chapter I – Introduction & Overview: no indicated changes  

Chapter II – Registration Procedures 

• To align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide. 

Chapter III – Policy Guidance: 

• To align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide. 

Chapter IV – Technical Information:  

• A clarification has been added that the reporting threshold does apply to non-trauma no-fault and workers’ compensation cases (Section 6.4).  

• The Event Table has been updated to include three new scenarios involving MSA corrections (Section 6.6.4).  

• To align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide. 

Chapter V – Appendices:  

• To align with new WCMSA reporting requirements effective April 4, 2025, field numbers have been updated throughout this guide.  

• To reflect improved reporting requirements, Zip+4 section guidance has been updated (Appendix A, Appendix B, and Appendix G).  

• To ensure consistency of data, as of October 6, 2025, the Recovery Agent TIN field is required if agent name is submitted (Appendix B and Appendix G). 

270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide for Mandatory Reporting Non-GHP Entities:  

• The email address for contacting an Electronic Data Interchange (EDI) Representative has changed to COBVA@bcrcgdit.com. However, COBVA emails coming from CMS now show the address as COBVA@mail.cms.hhs.gov (Customer Support). 

For information on any of these newly released documents, please contact Shawn Deane at J29 at shawn.deane@j29inc.com or at (866) 529-6771.   

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Author Bio   

Shawn Deane   

General Counsel & Vice President of Claims Solutions | J29   

Shawn.Deane@j29inc.com        

(866) 529-6771   

www.j29inc.com      

As General Counsel & Vice President of Claims Solutions, Shawn Deane leads J29’s legal and Medicare Secondary Payer (MSP) services team. Shawn is a practicing attorney and has over 17 years of experience in Medicare compliance, workers’ compensation, and insurance claims. He was previously General Counsel & Senior Vice President of Risk Management & Compliance at the nation’s largest professional administrator of Medicare Set Asides. Prior to that he was Vice President of Medicare Compliance & Policy at one of the country’s largest Medicare Set Aside vendors. He’s an industry expert and thought leader in workers’ compensation, Medicare Set Asides (MSAs) and Medicare compliance.    

About J29   

J29 is a women-owned business that offers Medicare Secondary Payer (MSP) compliance services providing Medicare Set Asides (MSAs), conditional payment / lien services and related solutions to all workers’ compensation stakeholders – including carriers, self-insureds, third-party administrators, and attorneys.  

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