The new year brought a few new changes to the Workers' Compensation Medicare Set Aside Reference Guide. Below is the announcement of the updated CMS reference guide. The changes noted are:
- Additional guidance around CMS' monitoring of WCMSA funds:
- "Additionally, the contractor must ensure that Medicare makes no payments related to the WC injury until the WCMSA has been used up. This is accomplished by placing an electronic marker in CMS’ systems used to pay or deny claims. That marker is removed once the beneficiary can demonstrate the appropriate exhaustion of an amount equal to the WCMSA plus any accrued interest from the account. For those with structured settlements, the marker is removed in any period where the beneficiary exhausts their available funds; however, it is replaced once the anniversary fund deposit occurs until the entire value of the WCMSA is demonstrated as entirely exhausted." - Section 18.0 of WCMSA Reference Guide 2.9
- Additional note about Medicare's interest being protected:
- "CMS’ voluntary, yet recommended, WCMSA amount review process is the only process that offers both Medicare beneficiaries and Workers’ Compensation entities finality, with respect to obligations for medical care required after a settlement, judgment, award, or other payment occurs. When CMS reviews and approves a proposed WCMSA amount, CMS stands behind that amount. Without CMS’ approval, Medicare may deny related medical claims, or pursue recovery for related medical claims that Medicare paid up to the full amount of the settlement, judgment, award, or other payment." - Section 4.2 of WCMSA Reference Guide 2.9
- Addition of threshold submission examples:
- "Example 1: A recent retiree aged 67 and eligible for Medicare benefits under Parts A, B, and D files a WC claim against their former employer for the back injury sustained shortly before retirement that requires future medical care. The claim is offered settlement for a total of $17,000.00. However, this retiree will require the use of an anti-inflammatory drug for the balance of their life. The settling parties must consider CMS’ future interests even though the case would not be eligible for review. Failure to do so could leave settling parties subject to future recoveries for payments related to the injury up to the total value of the settlement ($17,000.00).
- Example 2: A 47 year old steelworker breaks their ankle in such a manner that leaves the individual permanently disabled. As a result, the worker should become eligible for Medicare benefits in the next 30 months based upon eligibility for Social Security Disability benefits. The steelworker is offered a total settlement of $225,000.00, inclusive of future care. Again, there is a likely need for no less than pain management for this future beneficiary. The case would be ineligible for review under the non-CMS-beneficiary standard requiring a case total settlement to be greater than $250,000.00 for review. Not establishing some plan for future care places settling parties at risk for recovery from care related to the WC injury up to the full value of the settlement." - Section 8.1 of WCMSA Reference Guide 2.9
- “To eliminate issues around Development Letter and Alert templates auto populating with individual Regional Office (RO) reviewer names and direct phone numbers, these will now display the generic “Workers’ Compensation Review Contractor (WCRC)” and the WCRC customer service number “(833) 295-3773” (Appendix 5).
- Per CMS’ request, certain references to memoranda on cms.gov have been removed
- The CDC Life Table has been updated for 2015 (Section 10.3).
- Updates have been provided for spinal cord stimulators and Lyrica (Sections 9.4.5 and 18.104.22.168)”
- Example 1: Lyrica (Pregabalin) is cited in MicroMedEx for an off-label medication use related to neuropathic pain from spinal cord injury, and a number of scientific studies indicate that Pregabalin shows statistically significant positive results for the treatment of radicular pain (a type of neuropathic pain). Spinal cord neuropathy includes injuries directly to the spinal cord or its supporting structures causing nerve impingement that results in neuropathic pain. Lyrica is considered acceptable for pricing as a treatment for WCMSAs that include diagnoses related to radiculopathy because radiculopathy is a type of neuropathy related to peripheral nerve impingement caused by injury to the supporting structures of the spinal cord.
- Example 2: Routine replacement of the neurostimulator pulse generator includes the lead implantation up to the number of leads related to the associated code. Revision surgeries should only be used where a historical pattern of a need to relocate leads exists.
So how does this affect you?
- CMS is taking steps to track WCMSA settlements and spend more accurately, ensuring funds are spent appropriately before CMS steps in as primary payer. With Ametros' professional administration service, we ensure that funds are spent appropriately, reported properly, that benefits are protected, and we coordinate with CMS to step in as primary payer as appropriate.
- Reviewer names are now confidential, removing identity. You will now be directed towards a general phone line.
- CMS is using updated life tables to calculate rated ages and provide life expectancy or how long WCMSA's are calculated for. The life expectancy could impact the amount of your MSA
- CMS provides examples of when Lyrica would be included within an MSA
- Routine revisions will now include the lead implantation