In a Workers’ Compensation Medicare Set-Aside (WCMSA), allocations are determined individually, considering only items and services related to the workers’ compensation injury that Medicare would cover.
Key Factors in MSA Calculation
Post-settlement treatment, prescription drugs, and items are calculated based on multiple sources and factors, including:
- Applicable workers’ compensation fee schedules
- Usual and customary charges
- Actual charges, through reviewing claims payment and prescription drug payment histories
- Treatment records from the last two years
- Medical bills
- Facility or provider fees
Influence of Age and Injury Type on MSA Calculations
CMS notes that medical pricing may fluctuate depending on factors like injury, age, and location. Each submission undergoes an individual review, which means different claimants with similar injuries and ages could receive differing WCMSA amounts.
Prescription Drug Pricing in MSA
For prescription drugs, the Workers’ Compensation Review Contractor (WCRC) prices Part D drugs based on the Average Wholesale Price (AWP). This pricing considers both brand and generic formulations and uses data from the Truven Health Analytics’ Red Book, which is updated monthly.
Further Resources
For more detailed information on how WCMSAs are priced and allocated, consult the WCMSA Reference Guide.