Today, the Centers for Medicare and Medicaid Services (CMS) released version 3.9 of their Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) Reference Guide with a few modifications and additions, which we’ll address one-by-one below.
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Fading Role of Regional Offices
We are more than 20 years out from the debut of WCMSAs and over time the voluntary review process guidelines have moved from a series of CMS memos to the modern day Reference Guide format. The process evolved away from Regional Offices reviewing and approving allocations to use of a review contractor. This version of the Reference Guide contains changes to reflect the limited involvement by Regional Offices now.
Amended Review
Last fall, CMS released version 3.8 to clarify bases around “re-review,” which we blogged about here. Today they clarified a bit more about what happens when an errors exist in the submission. Beyond that, we are pleased to share that CMS tweaked their “Amended Review” process to make it more accessible for parties with a “stale” CMS approval. CMS will still only allow parties a one-time shot to revisit a previous CMS-approved Determination and at least one year has to have passed since the date of the Determination and its other review criteria are met. However, CMS removed its six year cap. In brief, the other criteria are: the case has not settled as of the date of the request for Amended Review; the projected care has changed such that the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount; and the approval of a new generic version of a medication by the Food and Drug Administration does not constitute a reason to request Amended Review by itself.
Intrathecal Pumps, Spinal Cord Stimulators, and Peripheral Nerve Stimulator Replacement Frequency
CMS clarified its Section 9.4.5 Medical Review Guidelines to assist allocators with pricing and replacement frequency calculations for intrathecal pumps, spinal cord stimulators, and added a section on peripheral nerve stimulator replacements.
New CDC Life Tables in Use
On April 24, 2023, CMS announced utilization of the Center for Disease Control and Prevention’s (CDC) “Table 1: Life Table for the total population: United States, 2020” for WCMSA life expectancy calculations effective April 29, 2023. The new reference guide incorporates that change as well.