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NEW RULES FOR WORKERS' COMPENSATION MEDICARE SET ASIDE ARRANGEMENTS
David Magaldi, Esquire and Steven Ledva, Jr., Esquire
(Continued from page 1)
The review of WCMSA proposals will not change in 2006. CMS's written opinion will still provide a total WCMSA amount which will now be a combination of the future medical treatment and prescription drug costs. CMS will begin independent pricing for future prescription drug treatments for WCMSAs received on or after January 1, 2007. When this occurs, the submitter will be required to include a payment history of the prescription drugs paid by the carrier as follows:
(1) If the injury occurred less than 2 years from the date of the submission, then a payment history should include all prescription drugs paid for from the injury date through the date of submission.
(2) If the injury occurred more than 2 years from the date of the submission, a payment history should include the last 2 years from the date of submission.
If the submitter fails to provide a payment history or the payment history reflects that the carrier did not pay for prescription drugs indicated for future treatment, CMS will independently price the prescription drugs using CMS information available from current Medicare Part D data.
The one issue that the December 30, 2005 memorandum failed to address is how it will treat a proposal which was submitted prior to the January 1, 2006 but was approved thereafter. The position of the Carrier should be that all proposals submitted prior to January should be treated under the pre-Part D standards. However, the significance of this issue has yet to unfold. In the next several months, one should be particularly vigilant in reviewing the approval letters to determine if prescription drug costs were added to the pre-January submissions.
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