Fourth Installment in our Tower MSA Partners Series

In our previous posts, we introduced the fundamentals of Medicare Set-Asides (MSAs), explained how they work, and outlined when an MSA is necessary. Now, we turn to the next important question: what exactly is included in an MSA?

At Tower MSA Partners, we ensure that every MSA is carefully developed to provide for the injured worker’s future medical care needs while protecting Medicare’s interests. In this article, we break down the typical components of an MSA allocation.

Future Medical Costs

The core of any MSA is the projection of future medical expenses related to the work injury or illness that Medicare would otherwise cover. These expenses include, but are not limited to:

• Physician visits (primary care and specialists)
• Hospitalizations
• Physical therapy
• Diagnostic testing (X-rays, MRIs, CT scans)
• Durable Medical Equipment (DME), such as wheelchairs or prosthetics
• Home health care services, if related to the injury
• Surgical procedures

Each projected cost is based on the injured worker’s medical history, current treatment plan, and anticipated future needs as determined through a comprehensive medical record review.

It is important to remember that CMS relies on the notes and opinions of the treating physician(s). Examining physicians, such as IMEs, PQMEs, AMEs, and the like, do not carry weight with CMS. Furthermore, statements from injured workers indicating that they do not plan to pursue a certain course of treatment, such as a spinal cord stimulator, will not be considered by CMS if a treating physician continues to recommend it as a treatment option.

Prescription Medications

In addition to medical services, the MSA must also allocate funds for prescription medications related to the injury. These include:

• Ongoing maintenance drugs (such as pain management medications)
• Antibiotics for recurring infections tied to the injury
• Future prescriptions based on ongoing treatment needs

It’s important that the medications included in the MSA are tied directly to the work-related condition and are likely to be needed based on current and reasonably foreseeable medical standards.

Treatment Trends and Cost Mitigation

Accurately projecting future care is essential to ensuring that the MSA is sufficient but not overinflated. This means factoring in:

• Discontinuation of treatments that are no longer medically necessary
• Weaning off medications (such as opioids) where clinically appropriate
• Updates or clarifications from treating physicians to mitigate outdated or unnecessary ongoing care assumptions

At Tower, we work closely with treating providers to clarify treatment plans and identify opportunities to right-size the MSA appropriately.

CMS Submission Documentation Requirements

If the MSA is submitted to the Centers for Medicare & Medicaid Services (CMS) for review and approval, there are specific documentation requirements:

• Submission of all relevant medical and pharmacy records for the most recent two years for each settling body part or condition
• The Medicare Set-Aside Report
• Claim payment history
• Claim prescription drug history
• Claimant executed Consent to Release form
• Clear explanation of how the MSA will be funded (lump sum vs. annuity) and administered (self-administered or professionally administered)
• If applicable, court orders, denial letters and depositions

Tower strives to provide a straightforward allocation for future medical care supported by the necessary treatment records and pharmacy history.  In doing so, we avoid CMS development letters and expedite the settlement process for the parties.

Conclusion

A properly developed Medicare Set-Aside includes a detailed projection of future medical costs, related prescription medications, and compliance with CMS submission requirements. Ensuring these elements are accurately captured is critical to protecting Medicare’s interests and the injured worker’s access to necessary care.

At Tower MSA Partners, our expert team builds MSAs that are precise, defensible, and compliant, helping you navigate settlements with confidence.

Stay tuned for our next blog in the series, where we will explore “What are Some Common MSA Challenges? “

Need assistance with your Medicare Set-Aside allocations? Contact Tower MSA Partners today.