06/08/10 CMS Clarifies the May 14 Memorandum.

Due to confusion from the 05/14/10 CMS Memorandum regarding the use of rated ages in Medicare Set-Aside proposals to CMS for their review, CMS issued a clarifying statement. The rated age certification now required by the May 14 memo must read:

"Our organization certifies that all rated ages we have obtained and/or have knowledge of regarding this claimant, and generated at any time on or after the Date of Incident for the alleged accident/illness/injury/incident at issue, have been included as part of this submission of a proposed amount for a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) to the Centers for Medicare & Medicaid Services."

This wording must be used in any proposal where rated ages are utilized, and no substitute wordings are permitted. All other requirements comprising acceptable proof of rated ages remain unchanged.

A copy of the memo can be found here: http://www.cms.gov/WorkersCompAgencyServices/Downloads/ClarifiedMay142010RatedAgeLanguageJune82010.pdf.



05/14/10 New CMS Policy Memorandum.

CMS issued a policy memorandum to clarify their previous memos dated April 3, 2009 and July 1, 2009 regarding prescription drugs, and the memo dated August 25, 2008 regarding rated ages.

According to the new memo, for a part D prescription drug to be covered by Medicare, and thus included in a Workers' Compensation Medicare Set-Aside, the drug should be prescribed for an outpatient use that is approved under the Federal Food, Drug, and Cosmetic Act [21 U.S.C.A. 301 et seq.], or supported by one or more citations included or approved for inclusion in any of the compendia described in subsection (g)(1)(B)(I) or 42 U.S.C. 1395r-8.

Therefore, prescription medications should only be included in the MSA for their FDA approved uses only.

For Work Comp settlements effectuated prior to 06/01/10, and if the settlement included non-covered part D drugs in the WCMSA, funds for the drugs will be considered an appropriate expenditure of the WCMSA. For Work Comp claims not settled prior to 06/01/10, and if the settlement includes non-covered part D drugs in the WCMSA, those cases may be re-priced and the funds not used for non-covered part D drugs. For any Work Comp settlement resolved after 06/01/10, and if the settlement does not include non-covered part D drugs in the WCMSA, those funds may not be used for non-covered part D drugs.

The memo also addressed the use of rated ages in WCMSA proposals. A statement indicating that all rated ages obtained have been included has been rescinded. The following statement must now be used:

"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."

No variations or substitute wording shall be accepted. Acceptable proof of rated ages must still be included with the WCMSA proposal.

A copy of the memo may be read here: http://www.cms.hhs.gov/WorkersCompAgencyServices/Downloads/WCMSARXGuidance6109.pdf.



03/23/10 Physical Therapy Exceptions.

President Barack Obama signed into law the Patient Protection and Affordable Care Act. A provision in this Act extended the physical therapy exceptions process until December 31, 2010. This over-rules our previous News post of 01/06/10.



03/23/10 The WCMSA Portal.

Latest update from the Centers for Medicare and Medicaid Services regarding development of the WCMSA Portal:

"The CMS is moving forward with the development of the Workers' Compensation Medicare Set-Aside Portal (WCMSAP). As you know, the WCMSAP will allow for electronic submission of WCMSA proposals for future medical and future prescription drug costs on a more expedited basis. With the introduction of the WCMSAP web portal, scehduled for the first quarter of 2011, WCMSA submitters will receive a real-time acknowledgement of their proposal submissions. Rest assured that comprehensive educational material will be provided on this website for all interested parties before the implementation of the WCMSAP. Keep checking back for updates that will be coming from CMS about the WCMSA Web Portal."



01/06/10 Physical Therapy Caps.

Congress chose not to extend the exceptions to the pysical therapy caps for 2010. Therefore, Medicare will only pay $1,860.00 for physical therapy services with no exceptions. Prior to 2010, a list of exceptions existed for certain diagnosis codes. A diagnosis code appearing on the list of exceptions would allow Medicare to pay any amount for physical therapy so long as the therapy was considered "medically necessary." With the failure to extend the exception list, now Medicare will pay no more than $1,860.00 for physical therapy services, regardless of the severity of the injury. Pending legislation in Congress could potentially extend the cap exceptions, however no action has yet occurred. This is the first time since 2006 that Congress has failed to extend the cap exceptions.

Hummel Consultation Services will continue to post developments as they occur.



10/26/09 Upcoming HCS Events.

Christine Hummel will be a featured speaker at the following pending events:

Pennsylvania Bar Assocation: The Carlisle Country Club in Carlisle, PA, November 12, 2009.
Kentucky Workers' Compensation Education Association Conference: The Sheraton Cincinnati Airport, KY, December 3-4, 2009.
New Jersey Institute for Continuing Legal Education: The New Jersey Law Center, New Brunswick, NJ, February 12, 2010.

Christine will also have an article published in the "Arizona Attorney," out in late 2009 or early 2010.



06/01/09 Prescription Drug Set-Aside Guidance for Submitters.

Questions and concerns raised from the treatment of prescription medications in WCMSA proposals to CMS as previously addressed in the April 3, 2009 Memorandum have been answered by CMS in a new statement released June 1, 2009. The text of the new statement can be read here.

Hummel Consultation Services has always completely complied with the issues addressed in this new statement. Any questions in regards to prescription medication treatment in MSA proposals may be directed to any of our staff at your convenience.



05/26/09 Regional Office Changes.

The Centers for Medicare and Medicaid Services announced that Medicare Set-Aside proposals for liability cases will be reviewed by all ten of their current Regional Offices. However, Workers' compensation proposals will now only be reviewed by six of their current Regional Offices. Effective immediately, the new assignments, as per jurisdiction of the claim, are:

Liability Proposals:

Boston = CT, ME, MA, NH, RI, VT
New York = NJ, NY, PR, VI
Philadelphia = DE, MD, PA, VA, WV, DC
Atlanta = AL, FL, GA, KY, MS, NC, SC, TN
Chicago = IL, IN, MI, MN, OH, WI
Dallas = AR, LA, NM, OK, TX
Kansas City = IA, KS, MO, NE
Denver = CO, MT, ND, SD, UT, WY
San Francisco = AZ, CA, HI, NV, GU, MP, AS, FM, MH, PW
Seattle = AK, ID, OR, WA

Workers' Compensation Proposals:

Boston = CT, ME, MA, NH, NY, PR, RI, VT, VI
Philadelphia = DE, DC, FL, MD, NJ, PA, TN, VA, WV
Chicago = GA, KY, IL, IN, MI, MN, OH, WI
Dallas = AL, AR, LA, MS, NM, NC, OK, SC, TX
San Francisco = AS, AZ, CA, CO, GU, HI, MT, NV, ND, MP, SD, UT, WY
Seattle = AK, ID, IA, KS, MO, NE, OR, WA

Hummel Consultation Services will make all changes necessary to our current or pending Medicare Set-Aside proposals to reflect the new Regional Office changes. Our customers do not need to take any action in regards to these changes.



04/03/09 New CMS Memorandum Released.

A new Centers for Medicare and Medicaid Services Memorandum was released on April 3, 2009 specifically addressing CMS procedures regarding the methodology of pricing future prescription drug treatment expenses in Workers' Compensation Medicare Set-Aside Arrangements.

As of June 1, 2009, prescription drug amounts are to be calculated using average wholesale price (AWP). No other pricing, discounting, or calculation methods will be allowed to determine the adequacy of the prescription drug amounts. This effectively eliminates the use of "dount-holes," out-of-pocket expenses, and any other discounts commonly used by other MSA vendors.

Hummel Consultation Services has never utilized these illicit means to lower prescription drug costs in its MSA proposals, nor have we ever endorsed the use of such. All of our MSA calculations effective immediately shall utilize the average wholesale price method endorsed by CMS.

Any staff member of Hummel Consultation Services may be contacted to discuss questions you may have regarding this very important Memorandum issued by CMS.

The full text of the new memorandum can be found here.



03/24/09 Liability Settlements and Medicare Set-Asides.

The Centers for Medicare and Medicaid Services recently held a conference call regarding the impending mandatory insurer reporting requirements. In an important development, CMS indicated that liability settlements must also protect Medicare's interests by ensuring the Medicare program does not pay for future medical expenses caused or necessitated by the injury or illness that is the subject of the liability settlement. CMS further stated that no formal review process is presently in place for liability Medicare Set-Asides but that the absence of this formal review process does not indicate a "safe harbor" that would excuse a liability settlement from protecting Medicare's interests. CMS further announced that the six regional CMS offices will make a decision on a per-office basis if that particular office will review liability Medicare Set-Asides. The decision is to be based on the workload on the specific regional office. To date, the only regional office to provide information on liability reviews is the Dallas office, which has verbally indicated that it plans to begin reviewing liability Medicare Set-Asides as early as June 2009.

We will continue to monitor these important changes regarding liability settlements and will immediately post all new information on this website as it is received.

Hummel Consultation Services is a leading provider of liability Medicare Set-Asides, and we would be more than happy to accept your liability referrals or answer any questions you may have. Please feel free to contact any of our staff for more information.



09/15/08 Implementation Timeline for Medicare Extension Act of 2007, Section 111, released.

As a follow-up to our News article of 12/29/07, below, the Centers for Medicare and Medicaid Services has announced a timeline for implementation of the Mandatory Reporting Statute for Liability and Workers' Compensation carriers. This implementation is a result of passage of the Medicare, Medicaid, and SCHIP Extension Act of 2007, 42 U.S.C. 1395y(b)(7)&(b)(8), specifically in regards to Section 111, the Medicare Secondary Payer Mandatory Reporting Provisions.

The timetable for liability insurance (including self-insurance,) no-fault insurance, and workers' compensation is as follows:

January 1, 2009 - June 30, 2009 : Recommended systems development period.
May 1, 2009 - June 30, 2009 : Electronic registration via the COBSW for all liability/no-fault/workers' compensation RREs.
July 1, 2009 - September 30, 2009 : Testing period for all liability/no-fault/workers' compensation RREs.
October 1, 2009 - December 31, 2009 : All liability/no-fault/workers' compensation RREs must submit their first Section 111 production files based upon a predetermined schedule with the COBC.
January 1, 2010 : All liability/no-fault/workers' compensation RREs must be submitting Section 111 production files by this date.

RRE = Responsible Reporting Entity, COBSW = Coordination of Benefits Secure Website

The entire memo addressing this timetable can be found here.



08/28/08 New CMS Policy Memorandum Released 08/25/08

The Centers for Medicare and Medicaid Services released a new policy Memorandum on August 25, 2008. This Memorandum focuses on two specific issues:

1. CMS issued specific guidelines regarding the handling of implantable devices, such as spinal cord stimulators, in set-aside allocations. CMS submissions must now include detailed pricing information regarding the device. Failure to provide this information will result in CMS utilizing its own cost-finding methodology. As a rule, Hummel Consultation Services has always included detailed pricing information for all items included in our CMS proposals.

2. CMS rescinded the rules outlined in Question 10 of the 07/11/05 Memorandum regarding the ability of beneficiaries to request terminations of MSA funding. Effective immediately, beneficiaries will no longer be allowed to request a termination in funding to their set-aside accounts for any reason.

A complete text of the new Memorandum can be found here.



08/27/08 New CMS Regional Office Assignments

Effective 09/01/08, CMS rearranged the number and assignments of their Regional Offices, removing four offices and retaining six. The four offices removed are Atlanta, Denver, Kansas City, and New York. The states serviced by those offices are reassigned to the remaining locations. The following link provides a list of the new assignments: link. The new assignments are as follows:

Boston = CT, ME, MA, NH, NY, PR, RI, VT, VI
Philadelphia = DE, DC, FL, MD, NJ, PA, TN, VA, WV
Chicago = GA, KY, IL, IN, MI, MN, OH, WI
Dallas = AL, AR, LA, MS, NM, NC, OK, SC, TX
San Francisco = AS, AZ, CA, CO, GU, HI, MT, NV, ND, MP, SD, UT, WY
Seattle = AK, ID, IA, KS, MO, NE, OR, WA

Hummel Consultation Services will apply the new office assignments for all of its current and pending CMS proposals; no action is necessary on the part of our customers!



07/15/08 Extension of Therapy Cap Exceptions

Legislation enacted 07/15/08 extends the effective date of the exceptions process to the therapy caps to 12/31/09. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,810.00 for calendar year 2008. For occupational therapy services, the limit is $1,810.00. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.

This legislation is an extension to that discussed in our news article for 12/29/07, below.



05/21/08 Hummel Consultation Services to Host MSA Seminar

Christine Hummel, in association with Ringler Associates, will be presenting a comprehensive seminar on Medicare Compliance at the Pontchartrain Convention Center in New Orleans, Louisiana on June 20, 2008 at 9:00am. All aspects of Medicare Compliance will be covered, including disputed claims, liability issues, and the Medicare lien search process. This seminar is appropriate for anybody concerned about Medicare compliance issues arising within their settlements, and is especially useful for claims adjusters, attorneys, and self-insured business owners.

Those involved in Longshore and Harbor Workers' disputes, and Jones Act disputes, may find this seminar to be especially beneficial.

Attendance is free for all; however, space for this important conference is limited, so be sure to reserve your spot as soon as possible.

For further information or to make a reservation, please contact Keith Christie at Ringler Associates by phone at (504) 454-9520, or by e-mail at kchristie@ringlerassociates.com.



05/20/08 New CMS Memorandum Released

The latest CMS Memorandum regarding the official policies of the Medicare Secondary Payer Program as it relates to Workers' Compensation was released today. This short Memorandum only addressed the correct life expectancy tables to be utilized when determining Medicare Set-Asides, and identified the correct table as the CDC Table 1, "Life table from the total population." Effective July 1, 2008, CMS will only accept MSA proposals utilizing this table.

The change will only affect proposals made after the July 1st date. It will have no impact upon rated age determinations.

The text of the latest CMS memo can be found here.
A copy of CDC Table 1 can be found here. Click the link for the 2004 tables.



12/29/07 New Legislation: Federal Notification and Penalties

President Bush signed Senate Bill 2499 into law at the end of 2007. Section 111, Paragraph 8 of the bill requires that by July of 2009, all liability, no-fault, and workers' compensation laws and plans, including self-insureds, must construct a plan that complies with the following provisions:

1. The insurer must make a determination whether a claimant, including individuals with unresolved claims, is entitled to benefits under the Medicare program on any basis, and

2. If the claimant is entitled to Medicare, to submit to the Secretary of Health and Human Services the following:
    A. The name of the claimant,
    B. Any other such information in order to make an appropriate determination concerning coordination of benefits,
    including any applicable recovery of benefits (i.e. to assert a lien.)

The information must be submitted to the Secretary within the time specified by the Secretary after the claim is resolved through settlement, judgment, award, or any other payment issued, regardless of a determination of admission or liability.

An applicable plan that fails to comply with the requirements of Section 111, Paragraph 8 with respect to any claimant shall be subject to a civil money penalty of $1,000.00 for each day of noncompliance with respect to each claimant.

Despite the passage of this Bill, several issues remain unclear at the present time. First, no indication was provided of when carriers must specifically give notice to the Secretary of the above provisions. Second, the law is vague regarding what precise information must be provided. It is hoped that the Centers for Medicare and Medicaid Services will provide additional clarification well before the provisions of this bill come into effect in July of 2009. Hummel Consultation Services will update this important release as it discovers further information.

The full text of Bill 2499 can be found here. Search for Bill Number S2499.



12/29/07 New 2008 Physical Therapy Caps

Senate Bill 2499, signed into law at the end of 2007, provides for new physical therapy cap amounts.

In 2008, the annual amount for physical and speech therapy (combined) is $1,810.00.
In 2008, the annual amount for occupational therapy is $1,810.00.

Congress took action late in December 2007 to extend the physical therapy cap exception process to June 30, 2008. Additional action shall be necessary by Congress to extend the cap exceptions beyond this date. The text of the exception process can be found in Senate Bill 2499, Section 105, here. Search for Bill number S2499.



05/25/07 Lumbar Artificial Disc Replacement

The Centers for Medicare and Medicaid Services is considering a proposed change regarding lumbar disc replacement procedures. Currently, artificial lumbar discs are authorized for persons over the age of 60, with one specific type of disc exempted from this policy. The proposed change will remove coverage for all artificial lumbar disc replacement procedures for all persons over the age of 60, regardless of the type of disc used.

The text of the proposed change can be found here.



03/14/07 CPAP Coverage Re-Evaluation

The Centers for Medicare and Medicaid Services is reconsidering the coverage of testing criteria and usage of Continuous Positive Airway Pressure (CPAP) therapy for obstructive sleep apnea (OSA). No change has been made to current coverage, but this may change depending upon the outcome of their evaluation.

The text of the reconsideration can be found here.



02/05/07 New Depression Coverage Consideration

A proposed decision for VAGUS Nerve Stimulation coverage.

The text of the proposal can be found here.