HR Tip: Workers’ Compensation Medicare Set-Aside (WCMSA) Re-Review process updated

 

The long-awaited update of the WCMSA Re-Review process by The Centers for Medicare and Medicaid Services (CMS) was issued in July. Section 12.4.3 provides the changes that have been made to the expanded Re-Review process.

Since CMS’ MSA review process has been in place, the Re-Review process has been somewhat limited. The update adds a third Re-Review option called an “Amended Review,” which reads, “You believe projected care has changed so much the new proposed amount would result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.”

To be eligible for an Amended Review, the following criteria must be met:

  • The MSA must have been originally submitted between one and four years from the date the re-review is submitted and
  • The re-review request cannot have had a previous request for an Amended Review and
  • Must result in a 10% or $10,000 change (whichever is greater) in CMS’ previously approved amount.

Only one Amended Review is permitted per case and another re-review cannot be requested if a request for an Amended Review is denied. As part of the review, generic drugs can be substituted for brand-named medicines but this cannot be the sole reason for the request. The request will consider medical and/or legal documentation that post-dates the CMS determination and medical circumstances that have changed.

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