Author: Durwin Fuller, Jr., Esq. CMSP
The Centers for Medicare & Medicaid Services (CMS) has continued to refine its guidance on Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) with the release of Version 4.5 of the WCMSA Reference Guide. Simultaneously, CMS conducted an important webinar clarifying the integration of WCMSA reporting requirements within the existing Section 111 Mandatory Insurer Reporting (MIR) framework under the Medicare Secondary Payer (MSP) Act.
These developments carry significant implications for workers’ compensation insurers, self-insureds, third-party administrators (TPAs), claimants, and their attorneys. Understanding the updates is essential to maintaining compliance, protecting Medicare’s interests, and avoiding costly penalties. As Medicare Secondary Payer (MSP) enforcement continues to evolve, CMS is making one thing clear: Workers’ Compensation Medicare Set-Aside Arrangements (WCMSAs) are no longer just a settlement issue — they are a reporting issue. CMS reliance on Section 111 data to coordinate benefits and prevent improper Medicare payments will continue to grow.
WCMSA Reference Guide Changes: Limited But Noteworthy Updates
In April 2026, CMS released Version 4.5 of the Workers’ Compensation Medicare Set‑Aside (WCMSA) Reference Guide, and while the updates are narrow in scope, they are relevant for practitioners who rely on the Guide for operational accuracy. Unlike prior revisions that introduced policy clarifications, Version 4.5 is primarily technical and administrative. Importantly, no substantive policy changes were made to WCMSA thresholds, approval standards, review methodology, or CMS’s Medicare Secondary Payer position.
CMS identifies only two updates in this version of the guide:
- Expanded zip code listings for Major Medical Centers
Additional zip codes were added to Appendix 7, which lists major medical centers. This update enhances geographic accuracy for those using the Appendix as a resource when developing WCMSA allocations that include surgeries and other procedures.
- Updated CDC Life Table Link
CMS updated the CDC Life Table hyperlink in Section 10.3, ensuring users are directed to the current life expectancy tables used in WCMSA development and review.
The changes matter because accurate life expectancy data and major medical center references play a supporting role in WCMSA development and post-settlement administration – particularly as CMS increases its reliance on data received through MMSEA Section 111 reporting.
CMS Webinar – WCMSA Reporting Through Section 111
On April 15, 2026, CMS conducted a widely anticipated webinar addressing the integration of WCMSA reporting obligations into the Section 111 Mandatory Insurer Reporting (MIR) framework. The webinar focused specifically on WCMSA reporting mechanics and common issues encountered since the WCMSA data fields went into effect. The presenters emphasized consistency, accuracy, and alignment between settlement documentation and reporting.
There were several clarifying points made both in the presentation and Q&A section of the webinar. First, CMS made clear that WCMSA reporting still applies only to Medicare beneficiaries. If the claimant is not a Medicare beneficiary at the time of settlement, WCMSA reporting is not required, even if the claimant becomes eligible shortly after settlement. For example, if a claim settles in June and the claimant becomes a Medicare beneficiary in July, WCMSA reporting is not required because the claimant was not a beneficiary on the TPOC date.
CMS confirmed how to determine the TPOC date:
- Signed settlement agreement controls, unless court approval is required
- If court approval is required, the TPOC date is the court approval date, not the execution date
CMS stressed consistency between settlement documents, WCMSA submissions and approvals, and Section 111 reporting data. Important clarifications included:
- Field 37 (MSA Amount) includes cents
- If a WCMSA is approved as structured but funded as a lump sum, CMS expects the information to match
- Changes should be submitted to the WCMSA review contractor
- If the Section 111-reported MSA amount differs from the CMS‑approved amount, the Section 111 reported MSA amount controls
CMS also confirmed that correcting an MSA amount through Section 111 reporting does not generate a new letter to the claimant. The claimant notification is issued only once, based on the initial report.
The webinar devoted a significant amount of time to multi-party and multi-DOI scenarios. Overall, the point was made that if there is a single claimant with a single settlement with multiple defendants, the earliest DOI should be reported by all defendants, and all applicable diagnosis codes must be reported. Furthermore, CMS distinguished reporting responsibilities:
Joint and several liability
- Each RRE reports the full TPOC and full MSA amount
Several liability only
- Each RRE reports only its proportionate responsibility
The takeaways from this webinar were very clear:
- WCMSA reporting is required even if CMS already approved the WCMSA
- Accuracy matters, but late or missing reports create risk
- Coordination between claims, legal, settlement consultants, and Section 111 reporting teams is essential
- WCMSAs are now firmly part of core Section 111 compliance, not an isolated settlement consideration
Contact us today for more information on how Allan Koba Compliance Solutions can help with your Medicare Secondary Payer (MSP) compliance needs.
