September 20, 2005 9:23 PM
In an effort to speed the process and obtain quicker review of proposed Workers' Compensation Medicare Set Aside Agreements (WCMSAA), CMS has published a sample 29 page sample submission. The sample submission provides:
1. Submitter Letter
--CMS will now assume that the proposed settlement date (PSD) will be within 4 months of submission, unless advised otherwise.
--Median Rated Age is defined
--Life Expectancy is computed using the 2001 CDC table 2 or 3. Also see the updated tables referenced
--Reference is made to "Seed Money" and a 6 stage computation formula discussed
2. Consent Form
--Sample format only
3. Rated Age Information or Life Expectancy
--The formats provided are the only acceptable formats that CMS will accept. These must be provided on settlement broker or insurance letterhead.
4. Life Care Plan
--Not mandatory, but suggested when the claimant's injury / disease is extensive/serious.
5. Settlement Agreement or Proposed Court Order
--Sample format only and will vary State by State.
6. Set-Aside Administrator/Copy of Agreement
--Sample for a self-administered WCMSA. Different criteria exist for a professionally-administered WCMSA.
7. Medical Records
--Sample format provided.
8. Payment History
--Payment history for medical and indemnity payments for the last two years must be included at the time of submission.
9. Chart of Threshold Criteria for Submission of a WCMSA
--Value over $250,000 and 30 Month Expectation ("Reasonable Expectation of Medicare enrollment within 30 months of settlement date.")
The sample has now been made available on the Internet:
Note: No reference has yet been made to Part D - Pharmaceutical coverage.
For Additional Information on this Website Search the term "CMS".
Smple Submission Form Avaiable at: