CMS recently released an updated version of the Workers’ Compensation Medicare Set-aside Arrangement Reference Guide (the Referenced Guide). The new version of the Reference Guide includes several important changes.
First, CMS has indicated that it “highly recommends professional administration where a claimant is taking controlled substances that CMS determines are ‘frequently abused drugs’” and generally recommends consideration of the use of a professional administrator for Medicare Set-asides.
Furthermore, CMS clarified that Workers’ Compensation Medicare Set-asides, whether self or professionally administered, must be administered in accordance with all Medicare coverage guidelines. This includes CMS’ Part D Drug Utilization Review policy. As such, CMS indicated that all Workers’ Compensation Medicare Set-aside administration programs should include Drug Management Programs for claimants at risk for abuse or misuse of “frequently abused drugs.”
CMS also clarified how hospital fee schedules are determined for Medicare Set-aside pricing and updated its guidance regarding how Medicare Set-aside funds may be distributed following the death of the claimant.
The updated version of the Reference Guide also amended the requirements for the contents of the consent form from the claimant required for submission of a Medicare Set-aside to CMS for review and approval. The updated language requirements include indication from the claimant that they understand the need for the Medicare Set-aside, the submission process, and approve of the contents of the submission.
Finally, CMS has extended the time frame for the Amended Review process. An Amended Review of CMS’ Medicare Set-aside determination can now be requested at least 12 months, but no more than 72 months, after the determination was issued. This is an increase of 24 months.