Frequently Asked Questions
Part D and Medicare Set-asides


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Part D and Workers' Compensation Medicare Set-aside Arrangements

  1. What is the Centers for Medicare & Medicaid Services' (CMS) policy regarding the inclusion of prescription drugs in WCMSAs with the implementation of the MMA?
  2. How does CMS define a WC "settlement"?
  3. What are CMS' submission requirements if the WC claim did not "settle" (as defined in Answer 2 above) prior to January 1, 2006?
  4. What happens if CMS closes its case because the submitter failed to provide requested information in a timely manner?
  5. Should submitters provide an explanation in the cover letter when the claimant has not been prescribed drugs for the work-related injury, illness/disease or if the drugs prescribed are excludable under the MMA?
  6. Where a WC claim settled prior to January 1, 2006, can the claimant use the WCMSA funds to pay for prescription drug expenses related to the WC injury?
  7. Should submitters include an amount for future prescription drug expenses if the claimant has not enrolled in a Part D plan?
  8. Has CMS' review of WCMSA proposals changed with the implementation of the MMA on January 1, 2006?
  9. What happens if a WCMSA proposal received by the COBC on or after January 1, 2006, does not include an amount for future prescription drug treatment?
  10. Has CMS published any guidelines about how to price for future prescription drug expenses in WCMSAs?
  11. Should funds for future prescription drug treatment be included in the calculation of the total settlement amount to determine if the WCMSA proposal should be reviewed by CMS?
  12. Do claimants have to resubmit their WCMSA proposals if CMS already issued a written opinion as to the total WCMSA amount?
  13. Will CMS begin to independently price for future prescription drug treatment in WCMSAs beginning on January 1, 2007?

Reference: CMSMEMO07-24-06.pdf

See also: http://que stions.cms.hhs.gov