A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease.

At time of settlement, employers submit the amount of the set aside for approval by CMS, and the amounts include significant sums for life time medication, often including opioids.

Over the last few years, the CMS estimate of future drug costs includes a calculation for opioids far in excess of what is reasonable, now that the opioid addiction crisis has focused more attention on drug addiction.

Finally, CMS has reacted to the opioid crisis and created new rules that may lower sums required by the WCMSA.

On April 2, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Medicare Advantage Plan (MAP) and Medicare Part D policy changes.

The new rule provides the plans “with new tools to improve quality of care and provide more plan choices for MA and Part D enrollees.” CMS estimates that the changes will result in $295 million in savings a year for the Medicare program over 5 years (2019 through 2023), which will ultimately result in lower premiums.

Noteworthy of the policy change is CMS’ policy changes relative to the Implementation of the Comprehensive Addiction and Recovery Act of 2016 (CARA).

CARA requires CMS to establish through regulation a framework that allows Part D Medicare prescription plans to implement drug management programs.

Under such programs, the Part D plans can limit at-risk beneficiaries’ access to coverage for frequently abused drugs beginning with the 2019 plan year. CMS will designate opioids and benzodiazepines as frequently abused drugs.

CMS will utilize Drug Management Programs as well as clinical guidelines used to determine if a beneficiary is potentially at-risk, which are based on using opioids from multiple prescribers and/or multiple pharmacies.

Part D plans will be allowed to limit an at-risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies). CMS will exempt beneficiaries who are being treated for active cancer-related pain, are receiving palliative or end-of-life care, or are in hospice or long-term care from drug management programs.

Thus CMS has issued this final rule with the goal of managing use of long-term, high-dose opioid and benzodiazepine usage.

In 2019 when these rules take effect, CMS should apply similar thinking to Workers’ Compensation Medicare Set-Aside (WCMSA) approvals in which the beneficiary is treating with high-dosage opioids.

If the Medicare Part D plan would no longer be responsible for paying for the drugs, it should not be included in the WCMSA. Likewise, CMS policy in discouraging long-term, highly-abused opioids should be applied across all CMS policy, including WCMSA policy review.