by Christopher N. Kleps, Esq.

A patient’s age, Social Security status, and the nature of the injury may make a Medicare Set-Aside (“MSA”) necessary during settlement in order to comply with federal law requiring parties to consider Medicare’s interest in not making medical payments for workers’ compensation injuries. In certain situations, the Centers for Medicare and Medicaid Services will review a proposed MSA allocation to determine if the recommended amount properly protects Medicare’s interests. Due to varying estimates for prescription medication costs, this review often results in a much higher “counter MSA” that the employer and insurer must pay if they wish to completely close medical.

A new online tool will soon be available through the Centers for Medicare and Medicaid Services website that may make the procedure more accurate. The new tool will allow users to input a patient’s life expectancy, prescriptions, dosage, and frequency, then calculate how much funding is needed for the prescription portion of the MSA. Since prescriptions often account for a huge portion of the MSA, this tool should allow for greater reliability of MSA preparation by vendors. The calculator will be available starting October 6th, and while it will generally be accessible to vendors or others who submit claims via the WCMSAP portal, it should allow vendors to more accurately estimate prescription values as mandated by the government. This in turn will help insurers decide whether to avoid the additional cost to submit an MSA allocation proposal to CMS when it is already apparent the cost will be too high to settle. More information is available here.