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What Criteria Does CMS Use When Reviewing an MSA?

By: Gregory Lisowski January 4, 2022 no comments

What Criteria Does CMS Use When Reviewing an MSA?

According to the WCMSA Reference Guide, the Workers’ Compensation Review Contractor will consider the following factors in making a decision about the adequacy your Medicare Set Aside:

• The past medical payment history for this case. (What medical expenses have been paid to date by the insurer?)

• The Claimant’s date of Medicare entitlement.

• The basis of Medicare entitlement. (Is the Claimant on Medicare because of disability, ESRD, or age?)

• The type and severity of the injury or illness claimed?
   a) Is full or partial recovery expected?
   b) If so, in what time frame?
   c) Is the individual an amputee, paraplegic or quadriplegic as a result of the work injury?
   d) Is the claimant’s condition stable, or might it improve or get worse?

• The Claimant’s age. (Is the WC injury likely to shorten the Claimant’s lifespan?)

• The type of benefits is the Claimant receiving. (e.g., permanent partial, permanent total disability, or a combination of both)

• The amount of the settlement, and how is it allocated between medical and indemnity.

• Is the settlement intended to last for the claimant’s lifetime, or for specific period?

• Does the WCMSA cover appropriate medical items and services for the Claimant’s condition? 


Source:  Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA)
Reference Guide COBR-Q4-2020-v3.2

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