Workers’ Compensation Medicare Set-Aside Reference Guide Issued for Spring

Today CMS issued an announcement that they have released Version 3.3 of the Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide (Reference Guide), which can be found here.  Per the new version, the changes included in this version of the guide are as follows:

  • The CDC Life Table link was updated (Section 10.3).
  • Language around surgeries to be covered by seed money in a structured settlement was clarified, and a disclaimer was added to the proposal review reference tools list in Appendix 4, along with the Conduent Strataware® tool (Sections 5.2 and 9.4.4,
  • Appendix 4).
  • Miscellaneous clarifications were added as follows (Sections 9.4.5, 10.2, 16.2, and 19.4):
    • On pricing: include refills when pricing intrathecal pumps.
    • On documentation: clarification was added on Consent to Release signatures.
    • On WCMSA Portal case access: clarification was added on case access for Professional Administrators who are not the original submitter.
  • The Major Medical Centers table was updated for a Missouri entry (Appendix 7).

The most noteworthy changes are those in regards to the seed money in a structured settlement, pricing regarding intrathecal pain pumps, allowance of an electric signature for consent to releases, and access to the portal for non-original submitters.

In regards to the seed money, CMS specifically included in this version that “In a structured WCMSA, an initial deposit is required to cover the first surgery or procedure for each body part, and/or replacement and the first two years of annual payments.” Furthermore, CMS goes on to note that “The seed includes the cost of the first surgery/procedure for each body part, including all costs such as prescription drugs, physician fees, anesthesia fees, and facility fees. If the surgery is preceded by an associated trial, i.e., trial SCS or trial intrathecal (IT) pump, the cost of the trial is also included since it is considered part of the same procedure. If there are no surgeries, the first procedure (if any, such as injections) is included. Series of spinal injections are not included, but series of knee viscosupplementation are included if three are anticipated to be accomplished as a series of three weekly injections.”

This differs from the current standards as in the past the most expensive procedure is what is utilized for the seed money. However, this seems to differ in that if there are procedures for several different body parts, all of those must be included in the seed amount and if said procedures include atrial and/or are administered in a series (i.e. specifically viscosupplementation injections which are traditionally given in a series of three) are to be included in the seed as well. This is interesting as annuities are commonly utilized to reduce the cost of MSAs will be less effective if larger seed amounts are required.

Additionally, CMS has expressly indicated that “Pricing includes necessary pump refills over the claimant’s life expectancy.”

In a change to enable easier submission of Consent to Releases, CMS has announced that they will now accept electronic signatures. As many may recall, the difficulty in getting a hand signature from Claimants with inadequate technology was a struggle, especially during the past year. However, in a loosening of requirements, CMS will now allow for individuals to sign via computer/electronic signature.

Finally, in regards to vendors that have taken over a submission and are not the original submitter of record, CMS has indicated “If there is a change in submitters, CMS requires a written release from services by the original submitter and a new signed Consent to Release form authorizing the new submitter. Both must be provided in order to continue the WCMSA review process. Professional Administrators whose EIN does not match the EIN of the original submitter, contact BCRC to gain access to the case via the WCMSA Portal; otherwise you must submit by mail. Submitter changes will not be accepted after settlement, and does not constitute a reason for a re-review (See Section 16.0 for re-review requirements). CMS will not provide copies of existing documentation to the new submitter. Any documentation must be obtained from the incumbent submitter or insurer.

CMS has previously required a signed withdrawal/release from the previous vendor and new authorization for the new submitter to go forward. However, CMS has interestingly now expressly stated that a change of submitter post settlement is not allowable and will not be a reason for re-review. Additionally, CMS has also indicated that it will not provide any copies of existing documentation to the new submitter. While this has been CMS’s historical practice, CMS has now expressly warned new submitters with this updated language.

The Gordon and Rees Medicare group will continue to follow this issue closely and will update you as soon as additional information is available.