MEDICARE SET-ASIDE (MSA) CALCULATION WORKSHEET

CASE INFORMATION

Case Caption: [________________________________]

Claimant Name: [________________________________]

Date of Birth: [__/__/____]

SSN (Last 4): XXX-XX-[____]

Date of Injury: [__/__/____]

Medicare Beneficiary Status: ☐ Current Beneficiary ☐ Reasonable Expectation within 30 months ☐ Not Applicable

Medicare Number (HICN/MBI): [________________________________]

Case Type: ☐ Workers' Compensation ☐ Liability/Personal Injury ☐ No-Fault

Proposed Settlement Amount: $[________________________________]

Prepared By: [________________________________]

Date Prepared: [__/__/____]

PART I: CMS REVIEW THRESHOLD DETERMINATION

A. Workers' Compensation MSA (WCMSA)

CMS Workload Review Thresholds:

Claimant Status:
☐ Currently entitled to Medicare (Part A or B)
☐ Reasonable expectation of Medicare enrollment within 30 months because:
☐ Age 62.5 or older
☐ Applied for SSDI
☐ Receiving SSDI
☐ Applied for SSI based on disability
☐ Receiving SSI based on disability
☐ Has ESRD
☐ No reasonable expectation of Medicare enrollment

Total Settlement Amount: $[____]

CMS Review Threshold Met: ☐ Yes ☐ No

Note: Even if CMS review threshold is not met, Medicare's interests must still be protected

B. Liability Medicare Set-Aside (LMSA)

Current CMS Guidance on LMSA:
☐ No formal CMS review process for LMSA
☐ Parties must consider Medicare's interests
☐ Voluntary submission not currently accepted

PART II: CLAIMANT MEDICAL INFORMATION

A. Injury/Condition Details

Primary Diagnosis (ICD-10):

Body Parts Affected:
☐ Head/Brain
☐ Neck/Cervical Spine
☐ Shoulder (☐ L ☐ R)
☐ Arm/Elbow (☐ L ☐ R)
☐ Wrist/Hand (☐ L ☐ R)
☐ Back/Thoracic Spine
☐ Lumbar Spine
☐ Hip (☐ L ☐ R)
☐ Knee (☐ L ☐ R)
☐ Leg/Ankle (☐ L ☐ R)
☐ Foot (☐ L ☐ R)
☐ Internal Organs: [____]
☐ Other: [____]

B. Current Treatment Status

Maximum Medical Improvement (MMI) Reached: ☐ Yes ☐ No

Date of MMI: [__/__/____]

Permanent Impairment Rating: [____]%

Current Treating Physicians:

C. Future Treatment Recommendations

Treating Physician's Recommendations:
[________________________________]
[________________________________]
[________________________________]

Independent Medical Examination (if applicable):
☐ Performed by: [________________________________]
☐ Date: [__/__/____]
☐ Recommendations: [________________________________]

PART III: FUTURE MEDICAL TREATMENT PROJECTIONS

A. Physician Services

Total Annual Physician Services: $[____]

B. Diagnostic Testing

Total Annual Diagnostic Testing: $[____]

C. Physical/Occupational Therapy

Total Therapy Costs: $[____]

D. Injections/Procedures

Total Annual Injection/Procedure Costs: $[____]

E. Future Surgeries

Total Future Surgery Costs: $[____]

F. Durable Medical Equipment (DME)

Total DME Costs: $[____]

PART IV: PRESCRIPTION MEDICATIONS

A. Current Medications Related to Injury

Total Annual Prescription Cost: $[____]

B. Medication Pricing

Pricing Source: ☐ Average Wholesale Price (AWP) ☐ Medicare Fee Schedule ☐ Actual Paid

CMS uses AWP from Truven Health Analytics Red Book for WCMSA pricing

Brand vs. Generic Considerations:
☐ Generic available for all medications
☐ Brand name medically necessary for: [________________________________]

PART V: MSA CALCULATION

A. Life Expectancy

Claimant Date of Birth: [__/__/____]

Current Age: [____]

Gender: ☐ Male ☐ Female

Life Expectancy (Years): [____]

Source: ☐ CDC Life Tables ☐ Social Security Tables ☐ Rated Age (adjusted for health)

If Rated Age Used:
Medical conditions affecting life expectancy: [________________________________]
Rated age adjustment: [____] years
Adjusted life expectancy: [____] years

B. Annual Treatment Cost Summary

C. One-Time/Non-Recurring Costs

D. MSA Calculation

Method 1: Simple Calculation

Annual Cost: $[____] x Life Expectancy: [____] years = $[____]

Plus One-Time Costs: $[____]

Total MSA (Simple Method): $[________________________________]

Method 2: Present Value Calculation (if applicable)

Note: CMS does not typically discount MSA to present value for lump-sum settlements

Total MSA Amount: $[________________________________]

PART VI: MSA FUNDING OPTIONS

A. Lump Sum Funding

Total MSA Amount: $[________________________________]

Advantages:
☐ Simplicity
☐ One-time transaction
☐ Claimant controls funds

Considerations:
☐ Interest earned can extend MSA
☐ Must maintain records
☐ Annual attestation may be required

B. Structured Settlement/Annuity Funding

Initial Deposit: $[________________________________]

Annual Payments: $[____] for [____] years

Total Guaranteed Payments: $[____]

Cost of Annuity: $[________________________________]

Annuity Provider: [________________________________]

Advantages:
☐ Lower upfront cost
☐ Guaranteed periodic payments
☐ Protection from fund depletion

Rated Age Annuity Available: ☐ Yes ☐ No

PART VII: CMS SUBMISSION (WCMSA)

A. Submission Checklist

Required Documentation:

☐ Cover letter
☐ Proposed WCMSA amount
☐ Settlement documents
☐ Claimant's consent form
☐ Medical records (2 years minimum)
☐ Physician's statement of future treatment
☐ Life expectancy documentation
☐ Prescription drug information
☐ DME information
☐ Proposed administration plan

B. Submission Information

Submission Type:
☐ Standard Submission (anticipated response: 45 days)
☐ Expedited Review (terminal illness)

CMS WCRC Submission Address:
WCMSAP
P.O. Box 138899
Oklahoma City, OK 73113-8899

Portal Submission: www.cob.cms.hhs.gov/MSPRP

Date Submitted: [__/__/____]

CMS Case ID: [________________________________]

C. CMS Response

Response Date: [__/__/____]

CMS Determination:
☐ Approved as submitted: $[____]
☐ Approved with modifications: $[____]
☐ Development letter issued
☐ Denied (reason): [________________________________]

CMS Approved MSA Amount: $[________________________________]

PART VIII: MSA ADMINISTRATION

A. Administration Options

Self-Administration:
☐ Claimant will self-administer
☐ Requires separate interest-bearing account
☐ Must maintain records of expenditures
☐ Annual attestation to CMS

Professional Administrator:
☐ Professional MSA administrator selected
☐ Administrator: [________________________________]
☐ Contact: [________________________________]
☐ Annual fee: $[____]

B. Account Requirements

Account Type: Interest-bearing checking or savings

Account Title: Medicare Set-Aside Account for [Claimant Name]

Financial Institution: [________________________________]

Account Number: [________________________________]

Initial Deposit: $[____]

Deposit Date: [__/__/____]

C. Record-Keeping Requirements

☐ Maintain all receipts and invoices
☐ Document all MSA expenditures
☐ Keep prescription drug records
☐ Retain bank statements
☐ Prepare annual attestation
☐ Report exhaustion of funds

PART IX: MSA REPORTING (Effective April 4, 2025)

A. Mandatory Reporting Elements

Per CMS Reference Guide Version 4.2, mandatory MSA reporting required

Reporting Entity: [________________________________]

Report Date: [__/__/____]

Required Information:

PART X: MSA SUMMARY

A. Final MSA Determination

B. Settlement Allocation

DOCUMENTATION CHECKLIST

☐ Medical records (minimum 2 years)
☐ Treating physician's statement
☐ All prescription information
☐ DME documentation
☐ Life expectancy calculation
☐ Settlement agreement
☐ CMS correspondence
☐ MSA approval letter
☐ Account opening documentation
☐ Administration agreement (if applicable)

VERIFICATION

Prepared By: [________________________________]

Date: [__/__/____]

MSA Specialist (if used): [________________________________]

Date: [__/__/____]

Attorney Review: [________________________________]

Date: [__/__/____]

SOURCES AND REFERENCES

• CMS Workers' Compensation Medicare Set-Aside Reference Guide (Version 4.2, April 2025)
• 42 U.S.C. § 1395y(b)(2) Medicare Secondary Payer provisions
• 42 C.F.R. § 411.46 Lump-sum settlements
• CMS WCMSA Portal: www.cob.cms.hhs.gov/MSPRP
• Medicare Prescription Drug pricing (AWP from Truven Red Book)
• CDC/NCHS Life Tables

This worksheet is for MSA calculation and tracking purposes. MSA requirements are complex and evolving. CMS guidance should be consulted, and professional MSA preparers may be appropriate for complex cases. Failure to properly consider Medicare's interests may result in liability.