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CMS Offers Clarity to Use of Non-Covered Part D Drugs and Rated Ages

On May 14, 2010, the Centers for Medicare and Medicaid Services (CMS) issued a new memo that attempts to clarify the use of non-covered part D drugs in a Workers Compensation Medicare Set Aside Arrangement (WCMSA). Per this latest memo:

1) Effective June 1, 2010, workers’ compensation cases that are settled prior to June 1, 2010, and include non-covered Part D drugs as part of the WCMSA, CMS will consider funds spent for those non-covered Part D drugs as being an appropriate expense from the WCMSA.
2) For those workers’ compensation claims that are not settled prior to June 1, 2010, and also include non-covered Part D drugs as part of the WCMSA, CMS will consider a re-pricing of those cases. Once the re-pricing has been completed, the claimant may not use the funds from their WCMSA to pay for non-covered Part D drugs.
3) For those workers’ compensation cases settled on or after June 1, 2010, and where the settlement does not include non-covered Part D drugs as part of the WCMSA, claimants may not use funds from their WCMSA to pay for those non-covered Part D drugs.

This memo also rescinds the previous rated age statement that stated “all rated ages obtained on the claimant have been included”. The new language regarding rated ages that must be included on all submissions reads as follows:

“Our organization certifies that all rated ages obtained on the claimant, at any time during that individual claimant’s lifetime, have been included as part of this submission to the Centers for Medicare & Medicaid Services.”

This latest memo goes onto state that the CMS will not accept any variations of this language, and that this language must be included without exceptions. If this language is not included than the CMS will not accept the rated age provided and will estimate the claimant’s remaining life expectancy using Actual Age. All previously released information on the use of rated ages for a claimant remain unchanged, and acceptable proof of rated ages is demonstrated through inclusion of independent rated ages on the letterhead of an insurance carrier or settlement broker.

To view this memo in it’s entirety, please click here.

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