Hello Jen,

My name is Mike from Chicago, Il. I have a WCMSA and self administer the arrangement. I pay my doctor according to the Illinois Workman's Compensation Fee Schedule which is discounted each month from $225.00 down to $95.27. I see this pain management doctor on a monthly basis to get my schedule II narcotics. I will be moving to Florida permanently as soon as my property sells in Chicago and was wondering at what rate do I pay the doctors in Florida? Since my WCMSA specifies an Illinois Work Comp Fee Schedule would I pay the doctors in Florida 100% of whatever their charges might be?  When I called CMS for the local Chicago region that's what the lady told me to do but I just want to make sure that it is the right thing to do. Am I not entitled to any Medicare discounted price at all?

Thank you for your help,

Dear Mike: 

Technically what little CMS guidance that is published would dictate is that you would continue to pay at the fee schedule rate which was governed by the jurisdiction in which your claim originated. In reality, the federal government has made no provisions that require any private medical service providers to accept WC rates absent an active WC claim, so your doctor should be commended for cooperating. The MSA has a valid purpose, it is just that the federal government has not done a great job of implementing a system for it.

If CMS says you can pay full charges in Florida, I would hope that you wrote down the name and job title of the person who told you that and the date that you called because I would view any oral information skeptically. Many of their employees do not fully understand the process themselves so their opinion will not be worth much unless you can prove you received it. Unless Barbara Wright or someone who works directly for her at the CMS MSP Central Office in Baltimore provided you with that information, I would remain skeptical. You may want to pose your question in writing to mspcentral@cms.hhs.gov and get a written response. Expect to wait 60 days or longer if they do choose to respond.

I would certainly try to negotiate the Florida WC price when you establish a new doctor relationship in Florida. If they understand what an MSA is, it may be no problem and may not care the claim originated in IL. What they get is instant payment rather than waiting for Medicare or an insurance carrier to pay and that has value to most providers. I checked a few areas around FL and the rate for the same office visit your getting in IL is $64 in most areas. The highest I found was $70 in Miami so that gives you a range to shoot for. If they don't like the rate, then you can tell them that you are legally bound by the IL Industrial Commission to pay only $95.27 and see what they do with that information. It's more than they get from FL or Medicare so that might appeal to them.  If all that fails, I would do as CMS says and just pay. When the money runs out sooner than expected, Medicare will only have themselves to blame.

I wish could provide you will some assurances that your move will be no problem but remember this is the federal government we are dealing with. Do the best you can with it. That's all they can hope for.

Enjoy your warm winter.

Jen Jordan

For questions about Medicare Set-Aside Arrangements as they pertain to liability settlements or general questions about your obligations under Section 111. Contact us at 888-SET-ASIDE.

MEDVAL 

1-888-SET-ASIDE

Medicare Set-Aside Allocation/Arrangement Recommendations

Submissions to Centers for Medicare and Medicaid Services

Post-Settlement Administration

Pharmacy Benefit Management