CMS Submission Quality Improvement Data Analytics National Alliance of Medicare Set- Aside Professionals Data and Development Committee Fran

Transcription

1 CMS Submission Quality Improvement Data Analytics National Alliance of Medicare Set- Aside Professionals Data and Development Committee Fran Provenzano Ciara Koba October 2017

2 of 3 hhs.gov/wcmsa/alertlookup!displayalertdetail?... 10/9/2017, 9:53 AM September 06, 2017 BRADY CONNOLLY AND MASUDA PC 10 S. LASALLE STREET SUITE 900 CHICAGO, IL RE: Workers Compensation Medicare Set-Aside Arrangement Claimant: Medicare ID/SSN: ***** Date of Injury: 09/06/2011 CMS Case Control Number(CCN): Dear Sir or Madam, This letter is in response to your submission of a proposed Workers Compensation Medicare Set Aside Arrangement (WCMSA) amount related to the above named claimant s workers compensation claim and received on 07/18/2017. You proposed a WCMSA amount of $19, to pay for future medical items and services that are covered and otherwise reimbursable by Medicare ("Medicare covered") and are related to the claimant s workers compensation claim. We note that you proposed $0.00 for Medicare covered prescription drugs. We have evaluated your proposal and have determined that $159, adequately considers Medicare's interests with respect to Medicare covered future medical items and services, including prescription drugs. In order to comply with Section 1862(b)(2) of the Social Security Act, Medicare is not permitted to pay for medical items or services, including prescription drug expenses, related to the workers compensation claim until the approved WCMSA amount is appropriately exhausted ("properly spent") on related medical care. Where a workers compensation settlement, judgment, award, or other payment is less than the approved WCMSA amount, Medicare is not permitted to pay for related medical care until the whole settlement, judgment, award, or other payment is properly spent on related medical care. The WCMSA funds must be placed in an interest bearing account. Funds in the account should not be used for any purpose other than payment of future medical care that is Medicare covered and is related to the workers compensation claim.

3 of 3 hhs.gov/wcmsa/alertlookup!displayalertdetail?... 10/9/2017, 9:53 AM The account must be funded by an initial deposit of $14, and subsequent equal payments of $6, over 21 year(s). When a WCMSA is funded as a structured settlement (settlement monies paid out in yearly installments over a number of years), any WCMSA funds that are not used in a given year must remain in the account to pay for related medical care during following years. If available WCMSA funds for a particular year (including the current year s full structured payment plus any prior year's remaining funds plus interest) have been properly spent, Medicare will pay for covered items and services that are related to the workers compensation claim for the remainder of that year until the scheduled date for the next year's deposit into the WCMSA account. Bills should be paid in the order they are received to help the Benefits Coordination & Recovery Contractor (BCRC) confirm that the funds have been temporarily exhausted (properly spent for that year). Approval of this WCMSA amount is not effective until the Centers for Medicare & Medicaid Services (CMS) receive a copy of the final executed workers compensation settlement agreement, which must include this approved WCMSA amount. Please include the CMS Case Control Number listed at the top of this letter in any correspondence. Submit your settlement agreement via the Portal if your original submission was via the Portal. If you originally submitted outside of the Portal, submit the settlement agreement to the following address: WCMSA Proposal/Final Settlement P.O. Box Oklahoma City, OK If your settlement agreement is 10 pages or less, you may also fax it to (405) Note: This number is not for initial submissions, only for additional documentation under 10 pages. The proposed WCMSA amount was calculated based on the workers compensation fee schedule for the State of ILLINOIS. Funds in a WCMSA may not be used to purchase a Medicare supplemental insurance policy or a Medigap policy for a beneficiary, or to pay for the premiums for such policies. Once the funds in the WCMSA account have been properly spent on Medicare-covered items and services related to the claimant s workers compensation claim and Medicare has been given proof that the account has been properly spent, Medicare will begin paying for the claimant s Medicare covered items and services that are related to the workers compensation claim. Medicare will pay for Medicare covered items and services that are unrelated to the workers compensation claim according to Medicare s payment rules. We understand that the claimant will act as administrator of the WCMSA funds. We have enclosed instructions, titled "Administering Your Workers Compensation Medicare Set-Aside Arrangement (WCMSA)." The WCMSA Self-Administration Toolkit is another resource, available on the CMS website at The claimant must send a signed attestation letter to the Benefits Coordination & Recovery Center at the address below every year, no later than 30 days after the end of each reporting period (beginning one year from the date of establishment of the WCMSA account). Annual attestations should continue through final exhaustion of the account. NGHP PO BOX

4 of 3 hhs.gov/wcmsa/alertlookup!displayalertdetail?... 10/9/2017, 9:53 AM OKLAHOMA CITY, OK Please note that this decision regarding future medical treatment is independent of any determination regarding Medicare Secondary Payer recovery rights for conditional payments Medicare made for related items and services furnished before the date of the settlement, judgment, award, or other payment. Medicare has the right to recover (or take back) Medicare payments related to any workers compensation settlement, judgment, award, or other payment. Any payments Medicare may have made that should have been paid from the workers compensation settlement, judgment, award, or other payment must be repaid to Medicare. If you have any questions concerning this letter, please call SUSAN SINGLER at (855) Sincerely, Sherri McQueen Acting Director, Financial Services Group Office of Financial Management Enclosure CC: NGHP

5 of /9/2017, 9:54 AM WORKERS COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT (WCMSA) REVIEW Case Control #: Medicare ID/SSN: ***** Claimant's Name: Date of Injury: 09/06/2011 Diagnosis Code: Dx Code Dx Ind. Dx Description F0789 ICD-10 Other personality and behavioral disorders due to known physiological condition F419 ICD-10 Anxiety disorder, unspecified M5116 ICD-10 Intervertebral disc disorders with radiculopathy, lumbar region M5418 ICD-10 Radiculopathy, sacral and sacrococcygeal region M5440 ICD-10 Lumbago with sciatica, unspecified side Proposed Settlement Date (PSD): 11/15/2017 Date of Birth: Age at PSD: 57 Rated Age at PSD: 62 Life Expectancy: 22 yrs. Submitter: (312) BRADY CONNOLLY AND MASUDA PC 10 S. LASALLE STREET SUITE 900 CHICAGO, IL Claimant: WCMSA Administrator: [] SSA's record shows Representative Payee Proposed Future Medical WCMSA Amount: $19, Proposed Future Rx WCMSA Amount: $0.00 Total Proposed WCMSA: $19, Proposed Initial Deposit: $1, Total Settlement Amount: $50,000.00

6 of /9/2017, 9:54 AM Recommended WCMSA: $159, Pricing Method: Fee WC State: ILLINOIS Recommended WCMSA Lump Sum [] or Recommended WCMSA Structured Payments: [X] Recommended Initial Deposit: $14, Annual Amount: $6, x 21 yrs. Anniversary Date: 11/15/2018 Type of Recommendation: Counter-Higher If not eligible for WCMSA, reason: Current Treatment Status for WC Injury or Disease (including past medical treatment): HE CLAIMANT SUSTAINED AN INDUSTRIAL INJURY ON 09/05/2011 TO THE LOW BACK WHILE WORKING BETWEEN THE TRUCK BED AND THE TRUCK. THE CLAIMANT FELL BETWEEN THE CAB AND TRAILER. IN 2013 A LUMBAR FUSION WAS PERFORMED. THE CLAIMANT DEVELOPED DEPRESSION AND ANXIETY. DIAGNOSIS INCLUDES LUMBAR RADICULOPATHY, DEPRESSION AND ANXIETY. TREATMENT HAS CONSISTED OF PHYSICIAN VISITS FOR ASSESSMENT, DIAGNOSTICS AND PHYSICAL THERAPY. Past Medical Treatment Unrelated to WC Injury or Its Co-Morbid Conditions: NO PAST OR UNRELATED HISTORY NOTED IN THE PROVIDED RECORDS Future Treatment (for Medicare-covered items and reimbursable services for the WC injury only): RECOMMENDED TREATMENT INCLUDES PHYSICIAN VISITS FOR ASSESSMENT, DIAGNOSTICS AND PHYSICAL THERAPY. The following chart summarizes the future medical treatment costs (exclusive of pharmacy items) that adequately protect Medicare's interests: Service Freq Every X Yrs # of Years Price Per Service Total ORTHOPEDIC VISITS $ $2, PHYSICIAN VISITS/PCP $ $6, LUMBAR MRI $1, $7, LUMBAR X-RAY $ $ METABOLIC PANEL $48.67 $1, COMPLETE BLOOD COUNT $30.50 $ VENIPUNCTURE $11.60 $ PHYSICAL THERAPY $ $2, Total: $22,376.18

7 of /9/2017, 9:54 AM Prescription Drugs (for Medicare-covered and reimbursable drugs for the WC injury only): (HYDROCODONE, ALPRAZOLAM, ONDANESTRON, TRAZODONE, DULOXETINE, OMEPRAZOLE AND MELOXICAM)WAS INCLUDED INTO THE WCMSA AS IT MET THE DEFINITION OF A MEDICARE PART D DRUG, WAS USED FOR A MEDICALLY ACCEPTABLE INDICATION, AND WAS FOUND TO BE PRESCRIBED FORA DIAGNOSIS RELATED TO THE INJURY WITHIN THE MEDICAL/PHARMACY RECORDS. According to available documentation, this claimant is currently receiving the following drugs: ONDANSETRON HYDROCHLOR..., ACETAMINOPHEN/HYDROCOD..., MELOXICAM, TRAZODONE HYDROCHLORIDE, DULOXETINE HYDROCHLORIDE, OMEPRAZOLE, ALPRAZOLAM, The following chart summarizes the future prescription drug costs that adequately protect Medicare's interests: Drug National Drug Code Amount Per Unit (Dosage) Per Day Per Week Per Month # of Years Price Per Units ACETAMINOPH MG-10 MG $0.64 $5, ALPRAZOLAM MG $0.88 $13, ONDANSETRON MG $0.94 $6, TRAZODONE H MG $0.41 $12, DULOXETINE MG $1.92 $45, OMEPRAZOLE MG $0.51 $8, MELOXICAM MG $2.78 $44, Total: $136, Total

8 of /9/2017, 9:54 AM Rationale for Decision: IN A REQUEST DATED 8/30/2017, COUNSEL FOR THE EMPLOYER REQUESTS A RE-REVIEW ON THE GROUNDS THAT MEDICATIONS WERE INCLUDED CONTRARY TO THE UTILIZATION REVIEW BY PRIUM DATED AUGUST 2, AS AN INITIAL MATTER, THE REVIEW DATED AUGUST 2, 2016 IS AN INFORMAL RECORDS REVIEW AND THE PROVIDER WAS NOT REQUIRED TO BE CONTACTED FOR THE REVIEW, AND IS NOT AN ACTUAL UTILIZATION REVIEW DETERMINATION. MOREOVER, EVEN IF THIS DETERMINATION WAS AN ACTUAL UTILIZATION HAS NOT PROVIDED AN "ALTERNATIVE TREATMENT PLAN SHOWING WHAT TREATMENT HAS REPLACED THE TREATMENT IN QUESTION FROM THE BENEFICIARY`S TREATING PHYSICIAN FOR THOSE ITEMS DEEMED UNNECESSARY BY THE UTILIZATION REVIEW BOARD." SEE WCMSA REFERENCE GUIDE SECTION (AUGUST1, 2017). A REVIEW OF THEMEDICAL RECORDS PROVIDED SUBSEQUENT TO THE 08/02/2016 PEER RECORD REVIEW, DEMONSTRATE THAT THE CLAIMANT CONTINUES TO RECEIVE THE FOLLOWING MEDICATIONS; ACETAMINOPHEN/HYDROCODONE, ALPRAZOLAM, DULOXETINE, MELOXICAM, OMEPRAZOLE, ONDANESTRON AND TRAZODONE; TO TREAT THE COMPENSABLE CONDITIONS: L4-5, L5-S1 FUSION (1/10/2013, L4-S1 HARDWARE REMOVAL, L4-5, AND HEMILAMINECTOMIES (2/6/2014) AN INITIAL DEPOSIT OF $14,459 INSTEAD OF THE SUBMITTER`S PROPOSED INITIAL DEPOSIT OF $1,921 WILL ADEQUATELY PROTECT MEDICARE`S INTEREST. 159,054 RECOMMENDED MSA, MINUS 0 A. COST OF 1ST SURG PROC (INCL PREP) 0 B. COST OF 1ST REPLACEMENT 0 C. RX INITIAL DEPOSIT 159,054 EQUALS REMAINING LIFE NEEDS22 LIFE EXPECTANCY 7,230 REMAINING NEEDS/LE= ANNUAL NEEDS 2 TIMES TWO YEARS 14,459 D. EQUALS TWO YRS OF REMAINING NEEDS 14,459 CALCULATED INITIAL DEPOSIT = A+B+C+D The following chart summarizes the services and costs that adequately protect Medicare s interests: Subtotal Future Treatment: $22, Subtotal Prescription Drugs: $136, Grand Total: $159,054.00

9 of /9/2017, 9:56 AM ADMINISTERING YOUR STRUCTURED WORKERS COMPENSATION MEDICARE SET ASIDE ARRANGEMENT (WCMSA) You have chosen to personally administer the WCMSA account established as part of a Workers Compensation (WC) settlement, judgment, award, or other payment. It is important that you understand the Centers for Medicare & Medicaid Services (CMS) policies regarding WCMSA accounts. In order to comply with Section 1862(b)(2) of the Social Security Act, Medicare is not permitted to pay for medical items or services, including prescription drug expenses, related to the workers compensation claim until the approved WCMSA amount is appropriately exhausted ("properly spent") on related medical care that is covered and otherwise reimbursable by Medicare ("Medicare covered"). Where a workers compensation settlement, judgment, award, or other payment is less than the approved WCMSA amount, Medicare is not permitted to pay for related medical care until the whole settlement, judgment, award, or other payment is properly spent on related medical care. The WCMSA funds must be placed in an interest bearing account. Funds in the account may not be used for any purpose other than payment of future medical care that is Medicare covered and is related to the workers compensation claim, or for certain allowable expenses. For details on using the account, see the WCMSA Reference Guide and the Self Administration Toolkit at on the CMS website. Funds in a WCMSA account may not be used to purchase a Medicare supplemental insurance policy or a Medigap policy, or to pay for the premiums for such policies. When a WCMSA is funded as a structured settlement (settlement monies paid out in yearly installments over a number of years), any WCMSA funds that are not used in a given year must remain in the account to pay for related medical care during later years. If available WCMSA funds for a particular year (the current year s full structured payment plus any prior year s remaining funds plus interest) have been properly spent, Medicare will pay for covered items and services that are related to the workers compensation claim for the remainder of that year until the scheduled date for the next deposit into the WCMSA account. Bills should be paid in the order they are received to help the Benefits Coordination & Recovery Contractor (BCRC) confirm that the funds have been properly spent for that year. Medicare will pay for items and services covered by Medicare that are unrelated to the workers compensation claim according to Medicare s payment rules. Basic instructions for establishing and administering a WCMSA account are listed below; more thorough instructions can be found in the Self Administration Toolkit mentioned above ( If you have any further questions regarding these requirements, please contact the Medicare Regional Office (RO) assigned to you. You can find a list of ROs at on the CMS web site; scroll to the Downloads section near the bottom of the page. For questions about annual attestations or annual accountings, contact the BCRC: NGHP PO BOX

10 of /9/2017, 9:56 AM OKLAHOMA CITY, OK Establishing and Using Your Medicare Set Aside Account WCMSA funds must be placed in an interest-bearing account, separate from your personal savings or checking account. WCMSA funds may only be used to pay for medical items and services and prescription drug expenses related to your workers compensation claim that would normally be paid by Medicare, or for certain allowable expenses. If you have a question regarding Medicare s coverage of a specific item, service, or prescription drug, please call MEDICARE ( ) or visit CMS website at where you can search for the item, service, or drug to see if it's covered. Note: If funds from the WCMSA account are used to pay for services other than Medicare allowable medical expenses related to the workers compensation claim, Medicare will not pay injury related claims until these funds are restored to the WCMSA account and then properly spent. Record Keeping You may use the WCMSA account to pay for the following costs that are directly related to the account: Document copying charges Mailing fees or postage Any banking fees related to the account Income tax on interest income from the account As administrator of the account, you will be responsible for keeping accurate records of payments made from the account. These records may be requested by the BCRC as proof of appropriate payments from the WCMSA account. Annually, you must sign and submit a copy of the attached attestation letter, which states that all payments from the WCMSA account were made for Medicare covered medical and prescription drug expenses related to the workers compensation claim, or for allowable expenses. An annual attestation must be submitted to the BCRC at the address listed on the first page of these instructions no later than 30 days after the end of each reporting year, which starts with the date the account is established and ends on that date in the following year. Funds remaining in the account at the end of a reporting year must remain in the account for the next year, along with any accrued interest. If your WCMSA funds are completely spent but you expect another annual deposit, send the attestation to inform Medicare that the account is temporarily exhausted. Medicare will pay for workers compensation claim related medical expenses until the next annual deposit. The annual attestation should continue through depletion of the WCMSA account. DO NOT SEND YOUR ANNUAL ATTESTATION DIRECTLY TO CMS. Please send your annual attestation to the BCRC.

11 of /9/2017, 9:56 AM Workers Compensation Medicare Set Aside Arrangement (WCMSA) Attestation of Expenditure for Structured Annuity This attestation should be completed annually or when your annual funds run out, whichever comes first, and mailed to the BCRC at "NGHP, PO Box , Oklahoma City, OK ," starting one year from the date the account is established. Note: Please make several copies of this attestation, because you must send it to the BCRC each year until all of your WCMSA funds have been spent properly on Medicare covered and otherwise reimbursable ("Medicare covered") medical and prescription drug expenses related to the workers compensation claim, or on allowable expenses. ALAN HUTCHISON *****0124A Date: Total WCMSA amount in CMS approval letter: $159, Individuals who have a CMS-approved WCMSA account as part of a workers compensation settlement agreement may only use the funds in the WCMSA account to pay for Medicare covered and otherwise reimbursable items and services that are related to the workers compensation claim. (Please circle one.) 1. I, the undersigned, attest that I have a structured annuity WCMSA and have used the monies from the WCMSA account for the period of to to pay for the following: Medical services: $ Prescription drug expenses: $ 2. I, the undersigned, attest that I have a structured annuity WCMSA and have EXHAUSTED the annual money (and any applicable carry over from previous years) in the WCMSA account for the period of to to pay for the following: Medical services: Prescription drug expenses: $ $ 3. I, the undersigned, attest that I have a structured annuity WCMSA and have COMPLETELY EXHAUSTED all monies in the WCMSA account to pay for the following: Medical services: $ Prescription drug expenses: $ I acknowledge and understand that failure to appropriately exhaust my WCMSA amount on Medicare-covered and otherwise reimbursable items and services, including prescription drugs, related to my workers compensation claim will result in Medicare denying payment for related medical items and services up to the approved WCMSA amount or the total workers compensation settlement, judgment, award, or other payment amount, whichever is less.

12 of /9/2017, 9:56 AM Signature Date Witness Date CMS reserves the right to audit how you spent the funds in your WCMSA account. Therefore, CMS recommends that you retain your WCMSA records for a period of seven (7) years. However, please do not send your receipts or bank statements to CMS or the BCRC except on request.

13 of /9/2017, 9:57 AM Workers Compensation Set Aside Re-Review Request Date of Request: 08/30/2017 Claimant: Medicare ID/SSN: ***** Date of Injury: 09/06/2011 CMS Case Control Number: Contact Name: LINDA PINNELL Contact Phone: (855) Requested By: Basis of Request: Submitter RX Reason for Re-Review Request: YOU BELIEVE CMS` DETERMINATION CONTAINS OBVIOUS MISTAKES (E.G., A MATHEMATICAL ERROR OR FAILURE TO RECOGNIZE MEDICAL RECORDS ALREADY SUBMITTED SHOWING A SURGERY, PRICED AT CMS, THAT HAS ALREADY OCCURRED). CMS Response: IN A REQUEST DATED 8/30/2017, COUNSEL FOR THE EMPLOYER REQUESTS A RE- REVIEW ON THE GROUNDS THAT MEDICATIONS WERE INCLUDED CONTRARY TO THE UTILIZATION REVIEW BY PRIUM DATED AUGUST 2, AS AN INITIAL MATTER, THE REVIEW DATED AUGUST 2, 2016 IS AN INFORMAL RECORDS REVIEW AND THE PROVIDER WAS NOT REQUIRED TO BE CONTACTED FOR THE REVIEW, AND IS NOT AN ACTUAL UTILIZATION REVIEW DETERMINATION. MOREOVER, EVEN IF THIS DETERMINATION WAS AN ACTUAL UTILIZATION HAS NOT PROVIDED AN "ALTERNATIVE TREATMENT PLAN SHOWING WHAT TREATMENT HAS REPLACED THE TREATMENT IN QUESTION FROM THE BENEFICIARY`S TREATING PHYSICIAN FOR THOSE ITEMS DEEMED UNNECESSARY BY THE UTILIZATION REVIEW BOARD." SEE WCMSA REFERENCE GUIDE SECTION (AUGUST1, 2017). A REVIEW OF THE MEDICAL RECORDS PROVIDED SUBSEQUENT TO THE 08/02/2016 PEER RECORD REVIEW, DEMONSTRATE THAT THE CLAIMANT CONTINUES TO RECEIVE THE FOLLOWING MEDICATIONS; ACETAMINOPHEN/HYDROCODONE, ALPRAZOLAM, DULOXETINE, MELOXICAM, OMEPRAZOLE, ONDANESTRON AND TRAZODONE; TO TREAT THE COMPENSABLE CONDITIONS: L4-5, L5-S1 FUSION (1/10/2013, L4-S1 HARDWARE REMOVAL, L4-5, AND HEMILAMINECTOMIES (2/6/2014)

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26 5/15/ May 15, 2017 EK HEALTH SERVICES, INC. 992 S. De Anza Blvd. Suite 101 San Jose, CA RE: Workers Compensation Medicare Set Aside Arrangement Claimant: HICN/SSN: Date of Injury: 04/08/2003 CMS Case Control Number(CCN): Dear Sir or Madam, This letter is in response to your submission of a proposed Workers Compensation Medicare Set Aside Arrangement (WCMSA) amount related to the above named claimant s workers compensation claim and received on 05/04/2017. You proposed a WCMSA amount of $18, to pay for future medical items and services that are covered and otherwise reimbursable by Medicare ("Medicare covered") and are related to the claimant s workers compensation claim. We note that you proposed $67, for Medicare covered prescription drugs. We have evaluated your proposal and have determined that $85, adequately considers Medicare's interests with respect to Medicare covered future medical items and services, including prescription drugs. In order to comply with Section 1862(b)(2) of the Social Security Act, Medicare is not permitted to pay for medical items or services, including prescription drug expenses, related to the workers compensation claim until the approved WCMSA amount is appropriately exhausted ("properly spent") on related medical care. Where a workers compensation settlement, judgment, award, or other payment is less than the approved WCMSA amount, Medicare is not permitted to pay for related medical care until the whole settlement, judgment, award, or other payment is properly spent on related medical care. The WCMSA funds must be placed in an interest bearing account. Funds in the account should not be used for any purpose other than payment of future medical care that is Medicare covered and is related to the workers compensation claim. 1/3

27 5/15/ The account must be funded by an initial deposit of $7, and subsequent equal payments of $3, over 22 year(s). When a WCMSA is funded as a structured settlement (settlement monies paid out in yearly installments over a number of years), any WCMSA funds that are not used in a given year must remain in the account to pay for related medical care during following years. If available WCMSA funds for a particular year (including the current year s full structured payment plus any prior year's remaining funds plus interest) have been properly spent, Medicare will pay for covered items and services that are related to the workers compensation claim for the remainder of that year until the scheduled date for the next year's deposit into the WCMSA account. Bills should be paid in the order they are received to help the Benefits Coordination & Recovery Contractor (BCRC) confirm that the funds have been temporarily exhausted (properly spent for that year). Approval of this WCMSA amount is not effective until the Centers for Medicare & Medicaid Services (CMS) receive a copy of the final executed workers compensation settlement agreement, which must include this approved WCMSA amount. Please include the CMS Case Control Number listed at the top of this letter in any correspondence. Submit your settlement agreement via the Portal if your original submission was via the Portal. If you originally submitted outside of the Portal, submit the settlement agreement to the following address: WCMSA Proposal/Final Settlement P.O. Box Oklahoma City, OK If your settlement agreement is 10 pages or less, you may also fax it to (405) Note: This number is not for initial submissions, only for additional documentation under 10 pages. The proposed WCMSA amount was calculated based on the workers compensation fee schedule for the State of CALIFORNIA. Funds in a WCMSA may not be used to purchase a Medicare supplemental insurance policy or a Medigap policy for a beneficiary, or to pay for the premiums for such policies. Once the funds in the WCMSA account have been properly spent on Medicare covered items and services related to the claimant s workers compensation claim and Medicare has been given proof that the account has been properly spent, Medicare will begin paying for the claimant s Medicare covered items and services that are related to the workers compensation claim. Medicare will pay for Medicare covered items and services that are unrelated to the workers compensation claim according to Medicare s payment rules. We understand that the claimant will act as administrator of the WCMSA funds. We have enclosed instructions, titled "Administering Your Workers Compensation Medicare Set Aside Arrangement (WCMSA)." The WCMSA Self Administration Toolkit is another resource, available on the CMS website at The claimant must send a signed attestation letter to the Benefits Coordination & Recovery Center at the address below every year, no later than 30 days after the end of each reporting period (beginning one year from the date of establishment of the WCMSA account). Annual attestations should continue through final exhaustion of the account. NGHP PO BOX OKLAHOMA CITY, OK Please note that this decision regarding future medical treatment is independent of any determination regarding Medicare Secondary Payer recovery rights for conditional payments Medicare made for related items and services furnished before the date of the settlement, judgment, award, or other payment. Medicare has the right to recover (or take back) Medicare 2/3

28 5/15/ payments related to any workers compensation settlement, judgment, award, or other payment. Any payments Medicare may have made that should have been paid from the workers compensation settlement, judgment, award, or other payment must be repaid to Medicare. If you have any questions concerning this letter, please call IAN FRASER at (415) Sincerely, Sherri McQueen Acting Director, Financial Services Group Office of Financial Management Enclosure CC: NGHP 3/3

29 5/15/ ADMINISTERING YOUR STRUCTURED WORKERS COMPENSATION MEDICARE SET ASIDE ARRANGEMENT (WCMSA) You have chosen to personally administer the WCMSA account established as part of a Workers Compensation (WC) settlement, judgment, award, or other payment. It is important that you understand the Centers for Medicare & Medicaid Services (CMS) policies regarding WCMSA accounts. In order to comply with Section 1862(b)(2) of the Social Security Act, Medicare is not permitted to pay for medical items or services, including prescription drug expenses, related to the workers compensation claim until the approved WCMSA amount is appropriately exhausted ("properly spent") on related medical care that is covered and otherwise reimbursable by Medicare ("Medicare covered"). Where a workers compensation settlement, judgment, award, or other payment is less than the approved WCMSA amount, Medicare is not permitted to pay for related medical care until the whole settlement, judgment, award, or other payment is properly spent on related medical care. The WCMSA funds must be placed in an interest bearing account. Funds in the account may not be used for any purpose other than payment of future medical care that is Medicare covered and is related to the workers compensation claim, or for certain allowable expenses. For details on using the account, see the WCMSA Reference Guide and the Self Administration Toolkit at on the CMS website. Funds in a WCMSA account may not be used to purchase a Medicare supplemental insurance policy or a Medigap policy, or to pay for the premiums for such policies. When a WCMSA is funded as a structured settlement (settlement monies paid out in yearly installments over a number of years), any WCMSA funds that are not used in a given year must remain in the account to pay for related medical care during later years. If available WCMSA funds for a particular year (the current year s full structured payment plus any prior year s remaining funds plus interest) have been properly spent, Medicare will pay for covered items and services that are related to the workers compensation claim for the remainder of that year until the scheduled date for the next deposit into the WCMSA account. Bills should be paid in the order they are received to help the Benefits Coordination & Recovery Contractor (BCRC) confirm that the funds have been properly spent for that year. Medicare will pay for items and services covered by Medicare that are unrelated to the workers compensation claim according to Medicare s payment rules. Basic instructions for establishing and administering a WCMSA account are listed below; more thorough instructions can be found in the Self Administration Toolkit mentioned above ( If you have any further questions regarding these requirements, please contact the Medicare Regional Office (RO) assigned to you. You can find a list of ROs at on the CMS web site; scroll to the Downloads section near the bottom of the page. For questions about annual attestations or annual accountings, contact the BCRC: NGHP PO BOX OKLAHOMA CITY, OK Establishing and Using Your Medicare Set Aside Account 1/4

30 5/15/ WCMSA funds must be placed in an interest bearing account, separate from your personal savings or checking account. WCMSA funds may only be used to pay for medical items and services and prescription drug expenses related to your workers compensation claim that would normally be paid by Medicare, or for certain allowable expenses. If you have a question regarding Medicare s coverage of a specific item, service, or prescription drug, please call MEDICARE ( ) or visit CMS website at where you can search for the item, service, or drug to see if it's covered. Note: If funds from the WCMSA account are used to pay for services other than Medicare allowable medical expenses related to the workers compensation claim, Medicare will not pay injury related claims until these funds are restored to the WCMSA account and then properly spent. Record Keeping You may use the WCMSA account to pay for the following costs that are directly related to the account: Document copying charges Mailing fees or postage Any banking fees related to the account Income tax on interest income from the account As administrator of the account, you will be responsible for keeping accurate records of payments made from the account. These records may be requested by the BCRC as proof of appropriate payments from the WCMSA account. Annually, you must sign and submit a copy of the attached attestation letter, which states that all payments from the WCMSA account were made for Medicare covered medical and prescription drug expenses related to the workers compensation claim, or for allowable expenses. An annual attestation must be submitted to the BCRC at the address listed on the first page of these instructions no later than 30 days after the end of each reporting year, which starts with the date the account is established and ends on that date in the following year. Funds remaining in the account at the end of a reporting year must remain in the account for the next year, along with any accrued interest. If your WCMSA funds are completely spent but you expect another annual deposit, send the attestation to inform Medicare that the account is temporarily exhausted. Medicare will pay for workers compensation claim related medical expenses until the next annual deposit. The annual attestation should continue through depletion of the WCMSA account. DO NOT SEND YOUR ANNUAL ATTESTATION DIRECTLY TO CMS. Please send your annual attestation to the BCRC. Workers Compensation Medicare Set Aside Arrangement (WCMSA) Attestation of Expenditure for Structured Annuity This attestation should be completed annually or when your annual funds run out, whichever comes first, and mailed to the BCRC at "NGHP, PO Box , Oklahoma City, OK /4

31 5/15/ ," starting one year from the date the account is established. Note: Please make several copies of this attestation, because you must send it to the BCRC each year until all of your WCMSA funds have been spent properly on Medicare covered and otherwise reimbursable ("Medicare covered") medical and prescription drug expenses related to the workers compensation claim, or on allowable expenses. EARNEST THOMPSON *****7241A Date: Total WCMSA amount in CMS approval letter: $85, Individuals who have a CMS approved WCMSA account as part of a workers compensation settlement agreement may only use the funds in the WCMSA account to pay for Medicare covered and otherwise reimbursable items and services that are related to the workers compensation claim. (Please circle one.) 1. I, the undersigned, attest that I have a structured annuity WCMSA and have used the monies from the WCMSA account for the period of to to pay for the following: Medical services: $ Prescription drug expenses: $ 2. I, the undersigned, attest that I have a structured annuity WCMSA and have EXHAUSTED the annual money (and any applicable carry over from previous years) in the WCMSA account for the period of to to pay for the following: Medical services: Prescription drug expenses: $ $ 3. I, the undersigned, attest that I have a structured annuity WCMSA and have COMPLETELY EXHAUSTED all monies in the WCMSA account to pay for the following: Medical services: $ Prescription drug expenses: $ I acknowledge and understand that failure to appropriately exhaust my WCMSA amount on Medicare covered and otherwise reimbursable items and services, including prescription drugs, related to my workers compensation claim will result in Medicare denying payment for related medical items and services up to the approved WCMSA amount or the total workers compensation settlement, judgment, award, or other payment amount, whichever is less. Signature Date Witness Date CMS reserves the right to audit how you spent the funds in your WCMSA account. Therefore, CMS recommends that you retain your WCMSA records for a period of seven (7) years. However, please do not send your receipts or bank statements to CMS or the BCRC except on request. 3/4

32 5/15/ /4

33 5/15/ WORKERS COMPENSATION MEDICARE SET ASIDE ARRANGEMENT (WCMSA) REVIEW Case Control #: HICN/SSN: Claimant's Name: Date of Injury: 04/08/2003 Diagnosis Code: Dx Code Dx Ind. Dx Description M179 ICD 10 Osteoarthritis of knee, unspecified M25569 ICD 10 Pain in unspecified knee M5417 ICD 10 Radiculopathy, lumbosacral region M545 ICD 10 Low back pain S335XXA ICD 10 Sprain of ligaments of lumbar spine, initial encounter Proposed Settlement Date (PSD): 09/01/2017 Date of Birth: 05/04/1959 Age at PSD: 58 Rated Age at PSD: 60 Life Expectancy: 23 yrs. Submitter: (408) EK HEALTH SERVICES, INC. 992 S. De Anza Blvd. Suite 101 San Jose, CA Claimant: WCMSA Administrator: [] SSA's record shows Representative Payee Proposed Future Medical WCMSA Amount: $18, Proposed Future Rx WCMSA Amount: $67, Total Proposed WCMSA: $85, Proposed Initial Deposit: $7, Total Settlement Amount: $138, Recommended WCMSA: $85, Pricing Method: Fee WC State: CALIFORNIA Recommended WCMSA Lump Sum [] or Recommended WCMSA Structured Payments: [X] Recommended Initial Deposit: $7, Annual Amount: $3, x 22 yrs. Anniversary Date: 09/01/2018 Type of Recommendation: Approved If not eligible for WCMSA, reason: 1/3

34 5/15/ Current Treatment Status for WC Injury or Disease (including past medical treatment): THE CLAIMANT SUSTAINED A WORK INJURY TO RIGHT KNEE AND LOW BACK ON 04/08/2003 DURING THE COURSE OF EMPLOYMENT AT SAFEWAY. THE CLAIMANT WAS DIAGNOSED WITH RIGHT KNEE MENISCUS TEAR AND LUMBAR SPRAIN/STRAIN. CLAIMANT UNDERWENT A RIGHT KNEE ARTHROSCOPICPARTIAL MENISECTOMY AND CHONDROPLASTY IN CLAIMANT CONTINUED TO HAVE RIGHT KNEE PAIN AND DEVELOPED LEFT KNEE PAIN DUE TO OVERUSE. CLAIMANT WAS DIAGNOSED WITH BILATERAL KNEE DEGENERATIVE ARTHRITIS. CLAIMANT RECEIVED SYNVISC INJECTIONS, PHYSICAL THERAPY AND MEDICATIONS. CLAIMANT WAS USING BRACES FOR BILATERAL KNEES. CLAIMANT REMAINED STABLE WITH MEDICATIONS AND BRACES. Past Medical Treatment Unrelated to WC Injury or Its Co Morbid Conditions: DEPRESSION, GERD, OSTEOARTHRITIS, HERNIA REPAIR, LEFT SHOULDER SURGERY, MVA WITH NECK AND LEFT WRIST INJURY, PARTIAL AMPUTATION OF RIGHT INDEX FINGER. Future Treatment (for Medicare covered items and reimbursable services for the WC injury only): THE FOLLOWING MEDICAL SERVICES WILL BE INCLUDED IN FUTURE CARE. The following chart summarizes the future medical treatment costs (exclusive of pharmacy items) that adequately protect Medicare's interests: Service Freq Every X Yrs # of Years Price Per Service Total ORTHOPEDIC SURGEON $89.81 $8, PHYSICAL THERAPY $ $4, COMPLETE BLOOD COUNT $10.59 $ COMPREHENSIVE METABO $14.39 $ VENIPUNCTURE $3.00 $69.00 RIGHT KNEE X RAY $63.15 $ RIGHT KNEE MRI $ $1, LEFT KNEE X RAY $63.15 $ LEFT KNEE MRI $ $1, LUMBAR X RAY $77.19 $ LUMBAR MRI $ $1, LEFT KNEE BRACE $ $ RIGHT KNEE BRACE $ $ RIGHT KNEE INJECTION $95.35 $ LEFT KNEE INJECTION $95.35 $ DEPO MEDROL 40MG (J $5.57 $33.42 Total: $19, Prescription Drugs (for Medicare covered and reimbursable drugs for the WC injury only): THE FOLLOWING MEDICATIONS WERE USED AND FOUND IN MEDICAL/PHARMACY RECORDS. According to available documentation, this claimant is currently receiving the following drugs: MELOXICAM, ACETAMINOPHEN/HYDROCODONE BITARTRATE, 2/3

35 5/15/ The following chart summarizes the future prescription drug costs that adequately protect Medicare's interests: Drug National Drug Code Amount Per Unit (Dosage) Per Day Per Week Per Month # of Years Price Per Units MELOXICAM MG $2.78 $46, ACETAMINOPH MG 10 MG $0.64 $21, Total: $67, Total Rationale for Decision: THE SUBMITTER`S PROPOSED SET ASIDE AMOUNT IS ADEQUATE TO PROTECT MEDICARE`S INTEREST. THE SUBMITTER`S PROPOSED INITIAL DEPOSIT OF $7, WILL ADEQUATELY PROTECT MEDICARE`S INTEREST. 85,580 RECOMMENDED MSA, MINUS 0 A. COSTOF 1ST SURG PROC (INCL PREP) 0 B. COST OF 1ST REPLACEMENT 0 C. RX INITIAL DEPOSIT 85,580 EQUALS REMAINING LIFE NEEDS 23 LIFE EXPECTANCY 3,721 REMAINING NEEDS/LE= ANNUAL NEEDS 2 TIMES TWO YEARS 7,442 D. EQUALS TWO YRS OF REMAINING NEEDS 7,442 CALCULATED INITIAL DEPOSIT = A+B+C+D The following chart summarizes the services and costs that adequately protect Medicare s interests: Subtotal Future Treatment: $19, Subtotal Prescription Drugs: $67, Grand Total: $87, /3

36 of 3 4/10/2017 8:19 AM April 10, 2017 EK HEALTH SERVICES, INC. 992 S. De Anza Blvd. Suite 101 San Jose, CA RE: Workers Compensation Medicare Set-Aside Arrangement Claimant: HICN/SSN: Date of Injury: 01/19/1988 CMS Case Control Number(CCN): Dear Sir or Madam, This letter is in response to your submission of a proposed Workers Compensation Medicare Set Aside Arrangement (WCMSA) amount related to the above named claimant s workers compensation claim and received on 02/07/2017. You proposed a WCMSA amount of $33, to pay for future medical items and services that are covered and otherwise reimbursable by Medicare ("Medicare covered") and are related to the claimant s workers compensation claim. We note that you proposed $18, for Medicare covered prescription drugs. We have evaluated your proposal and have determined that $161, adequately considers Medicare's interests with respect to Medicare covered future medical items and services, including prescription drugs. In order to comply with Section 1862(b)(2) of the Social Security Act, Medicare is not permitted to pay for medical items or services, including prescription drug expenses, related to the workers compensation claim until the approved WCMSA amount is appropriately exhausted ("properly spent") on related medical care. Where a workers compensation settlement, judgment, award, or other payment is less than the approved WCMSA amount, Medicare is not permitted to pay for related medical care until the whole settlement, judgment, award, or other payment is properly spent on related medical care. The WCMSA funds must be placed in an interest bearing account. Funds in the account should not be used for any purpose other than payment of future medical care that is Medicare covered and is related to the workers compensation claim.

37 2 of 3 4/10/2017 8:19 AM The account must be funded by an initial deposit of $51, and subsequent equal payments of $5, over 20 year(s). When a WCMSA is funded as a structured settlement (settlement monies paid out in yearly installments over a number of years), any WCMSA funds that are not used in a given year must remain in the account to pay for related medical care during following years. If available WCMSA funds for a particular year (including the current year s full structured payment plus any prior year's remaining funds plus interest) have been properly spent, Medicare will pay for covered items and services that are related to the workers compensation claim for the remainder of that year until the scheduled date for the next year's deposit into the WCMSA account. Bills should be paid in the order they are received to help the Benefits Coordination & Recovery Contractor (BCRC) confirm that the funds have been temporarily exhausted (properly spent for that year). Approval of this WCMSA amount is not effective until the Centers for Medicare & Medicaid Services (CMS) receive a copy of the final executed workers compensation settlement agreement, which must include this approved WCMSA amount. Please include the CMS Case Control Number listed at the top of this letter in any correspondence. Submit your settlement agreement via the Portal if your original submission was via the Portal. If you originally submitted outside of the Portal, submit the settlement agreement to the following address: WCMSA Proposal/Final Settlement P.O. Box Oklahoma City, OK If your settlement agreement is 10 pages or less, you may also fax it to (405) Note: This number is not for initial submissions, only for additional documentation under 10 pages. The proposed WCMSA amount was calculated based on the workers compensation fee schedule for the State of CALIFORNIA. Funds in a WCMSA may not be used to purchase a Medicare supplemental insurance policy or a Medigap policy for a beneficiary, or to pay for the premiums for such policies. Once the funds in the WCMSA account have been properly spent on Medicare-covered items and services related to the claimant s workers compensation claim and Medicare has been given proof that the account has been properly spent, Medicare will begin paying for the claimant s Medicare covered items and services that are related to the workers compensation claim. Medicare will pay for Medicare covered items and services that are unrelated to the workers compensation claim according to Medicare s payment rules. We understand that AMETROS/CAREGUARD will act as administrator of the WCMSA funds. Administrators must send attestations annually to the Benefits Coordination & Recovery Center at the address below no later than 30 days after the end of each reporting period (beginning one year from the date of establishment of the WCMSA account). Annual attestations should continue through final exhaustion of the account. We have enclosed instructions, titled "Professional Administration of Workers Compensation Medicare Set Aside Arrangement (WCMSA)." NGHP PO BOX OKLAHOMA CITY, OK 73113

38 of 3 4/10/2017 8:19 AM Please note that this decision regarding future medical treatment is independent of any determination regarding Medicare Secondary Payer recovery rights for conditional payments Medicare made for related items and services furnished before the date of the settlement, judgment, award, or other payment. Medicare has the right to recover (or take back) Medicare payments related to any workers compensation settlement, judgment, award, or other payment. Any payments Medicare may have made that should have been paid from the workers compensation settlement, judgment, award, or other payment must be repaid to Medicare. If you have any questions concerning this letter, please call IAN FRASER at (415) Sincerely, Sherri McQueen Acting Director, Financial Services Group Office of Financial Management Enclosure CC: NGHP AMETROS/CAREGUARD RONALD FEENBERG, ESQ.

39 of 1 4/10/2017 8:20 AM Workers Compensation Set Aside Re-Review Request Date of Request: Claimant: HICN/SSN: Date of Injury: CMS Case Control Number: 04/03/ /19/ IAN FRASER (415) Submitter Medical Contact Name: Contact Phone: Requested By: Basis of Request: Reason for Re-Review Request: YOU BELIEVE CMS` DETERMINATION CONTAINS OBVIOUS MISTAKES (E.G., A MATHEMATICAL ERROR OR FAILURE TO RECOGNIZE MEDICAL RECORDS ALREADY SUBMITTED SHOWING A SURGERY, PRICED AT CMS, THAT HAS ALREADY OCCURRED).BASED ON A REVIEW OF SUBMITTED MEDICAL RECORDS, AN ALLOCATION WAS APPROPRIATELY INCLUDED IN THE WCMSA FOR A SPINAL CORD STIMULATOR TRIAL. DR. AHMED INCLUDED A POSSIBLE PROVISION FOR A TRIAL IN HIS 03/21/16 REPORT. SUBSEQUENT RECORDS CLEARLY SHOW NO FORMAL REQUESTS, OR MENTION HAVE BEEN MADE TO PROCEED WITH A STIMULATOR TRIAL AND THE CLAIMANT'S CURRENT TREATMENT PLAN INCLUDES DIAGNOSTIC STUDIES, LUMBAR EPIDURAL STEROID INJECTIONS, AND MEDICATION MANAGEMENT. CMS Response: THE SUBMITTER'S RE-REVIEW REQUESTS REMOVAL OF THE SPINAL CORD STIMULATOR (SCS) IMPLANTATION AND REPLACEMENTS STATING ONLY A SCS TRIAL WAS RECOMMENDED AS A POSSIBLE TREATMENT OPTION. NO NEW EVIDENCE WAS SUBMITTED. AFTER REVIEW OF THE EXISTING RECORDS,IT IS NOTED THAT THE SUBMITTER ALLOCATED A SCS TRIAL IN THEIR PROPOSAL. SINCE THE CLAIMANT CONTINUES TO BE SYMPTOMATIC, THE SCS TRIAL REMAINS A PROBABLE FUTURE TREATMENT. SINCE THE SCS TRIAL HAS OCCURRED YET; IT IS NOT POSSIBLE TO PREDICT WHETHER PERMANENT SCS IMPLANTATION WILL OCCUR. HOWEVER, DUE TO THE POSSIBILITY OF PERMANENT SCS IMPLANTATION FOLLOWING A POTENTIAL SUCCESSFUL TRIAL, NO CHANGES WILL BE MADE TO THE WCMSA.

40 of 2 4/10/2017 8:21 AM PROFESSIONAL ADMINISTRATION OF WORKERS COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT (WCMSA) Federal regulations [42 Code of Federal Regulations (CFR) and ] provide that payment for work-related medical expenses and prescription drug expenses should not be shifted to Medicare from the responsible party. Accordingly, a portion of a claimant s Workers Compensation settlement may be set aside to pay for future work-related medical services and prescription drug expenses that would otherwise be reimbursable by Medicare. Medicare will not pay for any medical expenses or prescription drug expenses for the work-related injury, illness or disease after a Workers' Compensation settlement is received, until the amount allocated or Set-Aside for future medical expenses and future prescription drug expenses that would otherwise be reimbursable by Medicare are exhausted. When the approved WCMSA funds are depleted and a satisfactory accounting has been provided to the Centers for Medicare & Medicaid Services (CMS), Medicare will pay for any Medicarecovered medical treatment and Medicare-covered prescription drug expenses (if the beneficiary is enrolled in a prescription drug plan and has no other coverage primary to Medicare) received as a result of the injury sustained at work. However, failure to adhere to any of the following requirements will be regarded as a failure to reasonably recognize Medicare's interests and Medicare will deny coverage for all medical treatments and prescription drug expenses due to work-related injuries. The requirements are as follows: 1. Medicare Set-Aside Account - The WCMSA funds shall be placed in an interest bearing account, which is separate from any personal checking or savings account. A copy of the documents establishing the WCMSA account shall be sent to CMS at the following address within 30 days of disbursal of the Workers Compensation settlement. WCMSA Proposal/Final Settlement P.O. Box Oklahoma City, OK Note - If this case was submitted using the Workers Compensation Set-Aside Web Portal (WCMSAP), the documents must be attached and submitted to the case using the Web Portal. See the Case Documents section in the Web Portal case. 2. Distribution of funds from the Medicare Set-Aside Account - The funds in the WCMSA account shall be used solely for expenses related to medically necessary services or supplies or prescription drug expenses incurred for those medical needs related to or resulting from the work-related injury, which would otherwise be reimbursable or paid for by Medicare. Funds in the WCMSA account shall not be used to pay for medical services or prescription drug expenses not covered by Medicare. Examples of services and items not covered by Medicare include (but are not limited to) travel expenses for medical appointments, acupuncture, routine dental care, eyeglasses, and hearing aids. Medicare covered services are available in the booklet "Medicare & You" which can be obtained from any local Social Security office. If there are any questions concerning what Medicare covers, please call Medicare ( ) or visit the Medicare websites at 3. Set-Aside Account Interest - All interest earned on the Medicare Set-Aside account will be allowed to accrue in the account and will be used solely for medical expenses and prescription drug expenses that would otherwise be covered by Medicare and for banking fees, mailing fees, or document-copying charges related to the account.

41 of 2 4/10/2017 8:21 AM 4. Reimbursement to Medicare - In the event CMS determines that Medicare has erroneously paid benefits, CMS (or its designated Contractor) shall have the right to seek and receive reimbursement of any such conditional payments or overpayments. 5. Accounting Records - The administrator shall maintain accurate records of the distributions and expenditures from the WCMSA account. The records should indicate: the date of service; the name of the medical provider, supplier or pharmacy; the medical diagnosis, procedure, service, or item received; the amount paid for the medical expense or prescription drug expense; and the date of the payment. The administrator shall also retain a receipt or other evidence of each and every payment made from the WCMSA account. 6. Annual & Final Accountings and Delivery of Notices The administrator shall submit all required annual accountings of the WCMSA and notices to: NGHP PO BOX OKLAHOMA CITY, OK The annual accounting shall be submitted no later than 30 days after the close of the annual accounting period (which is the anniversary of the funding of the WCMSA from the Workers Compensation settlement). The administrator shall submit a final accounting within 60 days of the funds being depleted. The annual and final accountings will include the information set forth in paragraph 5 above. 7. Distributions Following Death of Beneficiary - In the event that the Medicare beneficiary dies before the funds in the WCMSA account are depleted, the account will continue to exist for payment of any outstanding bills for work-related injury medical expenses and prescription drug expenses that would otherwise be covered by Medicare. Any funds remaining in the WCMSA account after payment of all outstanding bills for work-related medical expenses and prescription drug expenses shall be paid to the beneficiary s estate or subject to State Law. 8. Inappropriate Set-Aside Account Expenditures - If, after the WCMSA account is depleted, the final accounting reveals that funds in the account were used to pay for items other than Medicare allowable expenses related to necessary services, supplies, or prescription drug expenses resulting from the work-related injury, Medicare will not pay for any future work-related medical expenses or prescription drug expenses until the funds have been restored to the account and properly exhausted.

42 of 4 4/10/2017 8:21 AM WORKERS COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT (WCMSA) REVIEW Case Control #: HICN/SSN: Claimant's Name: Date of Injury: 01/19/1988 Diagnosis Code: Dx Code Dx Ind. Dx Description G894 ICD-10 Chronic pain syndrome M4806 ICD-10 Spinal stenosis, lumbar region M5106 ICD-10 Intervertebral disc disorders with myelopathy, lumbar region M5126 ICD-10 Other intervertebral disc displacement, lumbar region M5136 ICD-10 Other intervertebral disc degeneration, lumbar region M5416 ICD-10 Radiculopathy, lumbar region M545 ICD-10 Low back pain Z9889 ICD-10 Other specified postprocedural states Proposed Settlement Date (PSD): 06/30/2017 Date of Birth: 03/05/1957 Age at PSD: 60 Rated Age at PSD: 63 Life Expectancy: 21 yrs. Submitter: (408) EK HEALTH SERVICES, INC. 992 S. De Anza Blvd. Suite 101 San Jose, CA Claimant: WCMSA Administrator: AMETROS/CAREGUARD PO BOX 827 BURLINGTON, MA [] SSA's record shows Representative Payee Proposed Future Medical WCMSA Amount: $33, Proposed Future Rx WCMSA Amount: $18, Total Proposed WCMSA: $51, Proposed Initial Deposit: $7, Total Settlement Amount: $175,000.00

43 of 4 4/10/2017 8:21 AM Recommended WCMSA: $161, Pricing Method: Fee WC State: CALIFORNIA Recommended WCMSA Lump Sum [] or Recommended WCMSA Structured Payments: [X] Recommended Initial Deposit: $51, Annual Amount: $5, x 20 yrs. Anniversary Date: 06/30/2018 Type of Recommendation: Counter-Higher If not eligible for WCMSA, reason: Current Treatment Status for WC Injury or Disease (including past medical treatment): THE CLAIMANT, EMPLOYED AS A MECHANIC, SUSTAINED A WORK INJURY DUE TO A FALL ON 1/19/1988 RESULTING IN LOW BACK PAIN. DIAGNOSES INCLUDE LUMBAR HERNIATED NUCLEUS PULPOSIS WITH RADICULOPATHY, LUMBAR DISC DEGENERATION AND STENOSIS, FAILED BACK SYNDROME.PAST TREATMENT INCLUDES A LUMBAR DECOMPRESSION IN 1991; POSTERIOR LUMBAR LAMINOTOMY AND FUSION, L4-5 IN 1992; 360 DEGREE LUMBAR FUSION ON 6/10/2006; AND LUMBAR SPINE PEDICLE SCREW REMOVAL ON 3/22/2008. ADDITIONAL TREATMENT HAS INCLUDED MEDICATIONS, LSO, INTERFERENTIAL STIMULATION, LUMBAR EPIDURAL STEROID INJECTIONS (LESIS), FACET BLOCKS WITH NEUROPLASTY, AND PHYSICAL THERAPY. IN 2016 THE CLAIMANT CONTINUED TO COMPLAIN OF ONGOING CHRONIC PAIN AND MEDICAL RECOMMENDATIONS INCLUDED LESIS, A DORSAL COLUMN SPINAL CORD STIMULATOR OR (SCS), IF UNSUCCESSFUL, AN INTRATHECAL MORPHINE PUMP. THE CURRENT DIAGNOSES INCLUDE CHRONIC PAIN SYNDROME, FAILED BACK SYNDROME, SPINAL STENOSIS, AND LUMBAR RADICULOPATHY. THE CLAIMANT IS INTERMITTENTLY EVALUATED BY THE ORTHOPEDIC AND PAIN MANAGEMENT PHYSICIANS FOR ONGOING ASSESSMENT, MEDICATION MANAGEMENT, AND MANAGEMENT OF RESIDUAL SYMPTOMS. Past Medical Treatment Unrelated to WC Injury or Its Co-Morbid Conditions: TOBACCO USE, RESTLESS LEG SYNDROME

44 of 4 4/10/2017 8:21 AM Future Treatment (for Medicare-covered items and reimbursable services for the WC injury only): FUTURE MEDICAL TREATMENT WILL INCLUDE PHYSICIAN VISITS, DIAGNOSTIC STUDIES, INJECTIONS, SPINAL CORD STIMULATOR TRIAL, SPINAL CORD STIMULATOR REPLACEMENT, SPINAL CORD STIMULATOR PROGRAMMING, AND PHYSICAL THERAPY. The following chart summarizes the future medical treatment costs (exclusive of pharmacy items) that adequately protect Medicare's interests: Service Freq Every X Yrs # of Years Price Per Service Total ORTHO VISITS $89.81 $7, PAIN MANAGEMENT VISI $ $2, COMPLETE BLOOD CELL $10.59 $ METABOLIC PANEL $14.39 $ VENIPUNCTURE $3.00 $63.00 DRUG SCREEN $79.94 $1, X-RAYS - LUMBAR $77.19 $ MRI LUMBAR $ $2, EMG/NCS $ $ LUMBAR STEROID INJEC $2, $6, SCS TRIAL $9, $9, SCS PLACEMENT/REPLAC $30, $90, SCS REPROGRAMMING $ $9, PHYSICAL THERAPY $ $2, Total: $134, Prescription Drugs (for Medicare-covered and reimbursable drugs for the WC injury only): MEDICATIONS ALLOCATED AS PRESCRIBED AND PER MEDICAL RECORDS AND PAYMENT HISTORY. HYDROCODONE/APAP WAS INCLUDED INTO THE WCMSA AS IT MET THE DEFINITION OF A MEDICARE PART D DRUG, WAS USED FOR A MEDICALLY ACCEPTABLE INDICATION, AND WAS FOUND TO BE PRESCRIBED FOR A DIAGNOSIS RELATED TO THE INJURY WITHIN THE MEDICAL/PHARMACY RECORDS. DULOXETINE WAS EXCLUDED FROM THE WCMSA AS THE WCRC DETERMINED IT WAS NO LONGER RECOMMENDED OR UTILIZED BY THE CLAIMANT. OMEPRAZOLE WAS ALLOCATED FOR A LARGER AMOUNT VERSUS THE SUBMISSION REQUEST, AS THE MEDICAL AND/OR PHARMACY RECORDS INDICATE THE INCREASE. According to available documentation, this claimant is currently receiving the following drugs: HYDROCODONE BITARTRATE-ACETAMINOPHE, OMEPRAZOLE, The following chart summarizes the future prescription drug costs that adequately protect Medicare's interests: Drug National Drug Code Amount Per Unit (Dosage) Per Day Per Week Per Month # of Years Price Per Units OMEPRAZOLE MG $0.51 $7, HYDROCODONE MG-10 MG $0.64 $19, Total: $27, Total

45 of 4 4/10/2017 8:21 AM Rationale for Decision: THE SUBMITTER'S RE-REVIEW REQUESTS REMOVAL OF THE SPINAL CORD STIMULATOR (SCS) IMPLANTATION AND REPLACEMENTS STATING ONLY A SCS TRIAL WAS RECOMMENDED AS A POSSIBLE TREATMENT OPTION. NO NEW EVIDENCE WAS SUBMITTED. AFTER REVIEW OF THE EXISTING RECORDS, IT IS NOTED THAT THE SUBMITTER ALLOCATED A SCS TRIAL IN THEIR PROPOSAL. SINCE THE CLAIMANT CONTINUES TO BE SYMPTOMATIC, THE SCS TRIAL REMAINS A PROBABLE FUTURE TREATMENT. SINCE THE SCS TRIAL HAS OCCURRED YET; IT IS NOT POSSIBLE TO PREDICT WHETHERPERMANENT SCS IMPLANTATION WILL OCCUR. HOWEVER, DUE TO THE POSSIBILITY OF PERMANENT SCS IMPLANTATION FOLLOWING A POTENTIAL SUCCESSFUL TRIAL, NO CHANGES WILL BE MADE TO THE WCMSA. AN INITIAL DEPOSIT OF $51,215 INSTEAD OF THE SUBMITTER`S PROPOSED INITIAL DEPOSIT OF $7,339 WILL ADEQUATELY PROTECT MEDICARE`S INTEREST. 161,541 RECOMMENDED MSA, MINUS 39,602 A. COST OF 1ST SURG PROC (INCL PREP) 0 B. COST OF 1ST REPLACEMENT 0 C. RX INITIAL DEPOSIT 121,939 EQUALS REMAINING LIFE NEEDS 21 LIFE EXPECTANCY 5,807 REMAINING NEEDS/LE= ANNUAL NEEDS 2 TIMES TWO YEARS 11,613 D. EQUALS TWO YRS OF REMAINING NEEDS 51,215 CALCULATED INITIAL DEPOSIT = A+B+C+D The following chart summarizes the services and costs that adequately protect Medicare s interests: Subtotal Future Treatment: $134, Subtotal Prescription Drugs: $27, Grand Total: $161,541.00

46 8/15/ August 15, 2017 EK HEALTH SERVICES, INC. 992 S. De Anza Blvd. Suite 101 San Jose, CA RE: Workers Compensation Medicare Set-Aside Arrangement Claimant: Medicare ID/SSN: Date of Injury: 04/29/1998 CMS Case Control Number(CCN): Dear Sir or Madam, This letter is in response to your submission of a proposed Workers Compensation Medicare Set Aside Arrangement (WCMSA) amount related to the above named claimant s workers compensation claim and received on 07/20/2017. You proposed a WCMSA amount of $169, to pay for future medical items and services that are covered and otherwise reimbursable by Medicare ("Medicare covered") and are related to the claimant s workers compensation claim. We note that you proposed $94, for Medicare covered prescription drugs. We have evaluated your proposal and have determined that $585, adequately considers Medicare's interests with respect to Medicare covered future medical items and services, including prescription drugs. In order to comply with Section 1862(b)(2) of the Social Security Act, Medicare is not permitted to pay for medical items or services, including prescription drug expenses, related to the workers compensation claim until the approved WCMSA amount is appropriately exhausted ("properly spent") on related medical care. Where a workers compensation settlement, judgment, award, or other payment is less than the approved WCMSA amount, Medicare is not permitted to pay for related medical care until the whole settlement, judgment, award, or other payment is properly spent on related medical care. The WCMSA funds must be placed in an interest bearing account. Funds in the account should not be used for any purpose other than payment of future medical care that is Medicare covered and is related to the workers compensation claim. 1/3

47 8/15/ The account must be funded by an initial deposit of $89, and subsequent equal payments of $19, over 25 year(s). When a WCMSA is funded as a structured settlement (settlement monies paid out in yearly installments over a number of years), any WCMSA funds that are not used in a given year must remain in the account to pay for related medical care during following years. If available WCMSA funds for a particular year (including the current year s full structured payment plus any prior year's remaining funds plus interest) have been properly spent, Medicare will pay for covered items and services that are related to the workers compensation claim for the remainder of that year until the scheduled date for the next year's deposit into the WCMSA account. Bills should be paid in the order they are received to help the Benefits Coordination & Recovery Contractor (BCRC) confirm that the funds have been temporarily exhausted (properly spent for that year). Approval of this WCMSA amount is not effective until the Centers for Medicare & Medicaid Services (CMS) receive a copy of the final executed workers compensation settlement agreement, which must include this approved WCMSA amount. Please include the CMS Case Control Number listed at the top of this letter in any correspondence. Submit your settlement agreement via the Portal if your original submission was via the Portal. If you originally submitted outside of the Portal, submit the settlement agreement to the following address: WCMSA Proposal/Final Settlement P.O. Box Oklahoma City, OK If your settlement agreement is 10 pages or less, you may also fax it to (405) Note: This number is not for initial submissions, only for additional documentation under 10 pages. The proposed WCMSA amount was calculated based on the workers compensation fee schedule for the State of CALIFORNIA. Funds in a WCMSA may not be used to purchase a Medicare supplemental insurance policy or a Medigap policy for a beneficiary, or to pay for the premiums for such policies. Once the funds in the WCMSA account have been properly spent on Medicare-covered items and services related to the claimant s workers compensation claim and Medicare has been given proof that the account has been properly spent, Medicare will begin paying for the claimant s Medicare covered items and services that are related to the workers compensation claim. Medicare will pay for Medicare covered items and services that are unrelated to the workers compensation claim according to Medicare s payment rules. We understand that AMETROS/CAREGUARD will act as administrator of the WCMSA funds. Administrators must send attestations annually to the Benefits Coordination & Recovery Center at the address below no later than 30 days after the end of each reporting period (beginning one year from the date of establishment of the WCMSA account). Annual attestations should continue through final exhaustion of the account. We have enclosed instructions, titled "Professional Administration of Workers Compensation Medicare Set Aside Arrangement (WCMSA)." NGHP PO BOX OKLAHOMA CITY, OK Please note that this decision regarding future medical treatment is independent of any determination regarding Medicare Secondary Payer recovery rights for conditional payments Medicare made for related items and services furnished before the date of the settlement, judgment, award, or other payment. Medicare has the right to recover (or take back) Medicare 2/3

48 8/15/ payments related to any workers compensation settlement, judgment, award, or other payment. Any payments Medicare may have made that should have been paid from the workers compensation settlement, judgment, award, or other payment must be repaid to Medicare. If you have any questions concerning this letter, please call LIZ BROWN ROBINSON at (855) Sincerely, Sherri McQueen Acting Director, Financial Services Group Office of Financial Management Enclosure CC: 3/3

49 8/15/ Workers Compensation Set Aside Re-Review Request Date of Request: Claimant: Medicare ID/SSN: Date of Injury: CMS Case Control Number: Contact Name: Contact Phone: Requested By: Basis of Request: Reason for Re-Review Request: YOU BELIEVE CMS` DETERMINATION CONTAINS OBVIOUS MISTAKES (E.G., A MATHEMATICAL ERROR OR FAILURE TO RECOGNIZE MEDICAL RECORDS ALREADY SUBMITTED SHOWING A SURGERY, PRICED AT CMS, THAT HAS ALREADY OCCURRED).IT APPEARS THE WCRC HAS BASED THE ALLOCATION FOR THE USE OF PSYCHIATRIC MEDICATIONS ON A REPORT WHICH IS MORE THAN A YEAR OLD FROM STEPHEN WILSON, M.D. (DATED 06/08/16). THE PHARMACY PAYMENT HISTORY CLEARLY INDICATES NO PRESCRIPTIONS WERE ISSUED TO THE CLAIMANT FOR THE USAGE OF ARIPIPRAZOLE BEYOND THE LAST FILL ON 12/03/15. AS SUCH, THERE IS NO CURRENTLY LIABILITY FOR EITHER THE SELF-INSURED EMPLOYER OR MEDICARE FOR THE PAYMENT OF THIS MEDICATION AS ITS USE IS NOT BEING RECOMMENDED. THANK YOU CMS Response: THE SUBMITTER'S RE-REVIEW REQUESTS THE FOLLOWING: 1.) REMOVE NORCO, SOMA, FLEXERIL AND PROZAC AS THEY HAVE BEEN DENIED BY UR AND IMR DETERMINATIONS. 2.) REMOVE WELLBUTRIN AS THE LAST FILL WAS 8/7/16. 3.) REMOVE VISTARIL AS IT WAS LAST FILLED ON 4/28/15 4.) REMOVE ABILIFY AS IT WAS LAST FILLED ON 12/3/15, AND 5.) REDUCE THE SPINAL CORD STIMULATOR (SCS) PRICING TO HISTORICAL PRICING. NEW EVIDENCE INCLUDES UR AND IMR STANDARDS. AFTER REVIEW OF THE NEW EVIDENCE AND EXISTING RECORDS, THERE HAS BEENNO DOCUMENTATION OF RESOLUTION OF THE PSYCH CONDITION; NOR HAS THERE BEEN EVIDENCE OF DISCONTINUATION OF THE PSYCH DRUGS; THEREFORE, THE FOLLOWING DETERMINATIONS HAVE BEEN MADE: 1.) NORCO, SOMA, FLEXERIL AND PROZAC CONTINUE TO BE PRESCRIBED BY THE T REATING PHYSICIAN AND THE TREATING PHYSICIAN HAS NOT 1/2

50 8/15/ PROVIDED AN ALTERNATIVE TREATMENT PLAN; THEREFORE, THESE MEDICATIONS WILL NOT BE REMOVED. 2.) ACCORDING TO DR. WILSON`S (PSYCH) LETTER ON 6/8/2016, CLAIMANT CONTINUES TO TAKE WELLBUTRIN. WELLBUTRIN WAS CERTIFIED BY SEDGWICK VIA AN RFA ON 6/29/16; THEREFORE, THIS DRUG WILL NOT BE REMOVED. 3.) ACCORDING TO DR. WILSON`S (PSYCH) LETTER ON 6/8/2016, CLAIMANT CONTINUES TO TAKE VISTARIL. VISTARIL WAS CERTIFIED BY SEDGWICK VIA AN RFA ON 6/29/16; THEREFORE, VISTARIL WILL NOT BE REMOVED. 4.) ACCORDING TO DR. WILSON`S (PSYCH) LETTER ON 6/8/2016, CLAIMANT CONTINUES TO TAKE ABILIFY. ABILIFY WAS CERTIFIED BY SEDGWICK VIA AN RFA ON 6/29/16; THEREFORE, ABILIFY WILL NOT BE REMOVED. 5.) THE SCS PRICING WAS BASED ON THE WBMSA REFERENCE GUIDE'S RECOMMENDED CPT CODES AND THE MOST CURRENT CA WC FEE SCHEDULE AND WILL NOT BE CHANGED OR REDUCED. PLEASE REFER TO THE UPDATED 7/10/17 WCMSA REFERENCE GUIDE SECTION FOR EXPANDED STATE-SPECIFIC STATUTE GUIDELINES AND UPDATED DEFINED REQUIREMENTS FOR SCS PRICING. 2/2

51 8/15/ PROFESSIONAL ADMINISTRATION OF WORKERS COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT (WCMSA) Federal regulations [42 Code of Federal Regulations (CFR) and ] provide that payment for work-related medical expenses and prescription drug expenses should not be shifted to Medicare from the responsible party. Accordingly, a portion of a claimant s Workers Compensation settlement may be set aside to pay for future work-related medical services and prescription drug expenses that would otherwise be reimbursable by Medicare. Medicare will not pay for any medical expenses or prescription drug expenses for the work-related injury, illness or disease after a Workers' Compensation settlement is received, until the amount allocated or Set- Aside for future medical expenses and future prescription drug expenses that would otherwise be reimbursable by Medicare are exhausted. When the approved WCMSA funds are depleted and a satisfactory accounting has been provided to the Centers for Medicare & Medicaid Services (CMS), Medicare will pay for any Medicarecovered medical treatment and Medicare-covered prescription drug expenses (if the beneficiary is enrolled in a prescription drug plan and has no other coverage primary to Medicare) received as a result of the injury sustained at work. However, failure to adhere to any of the following requirements will be regarded as a failure to reasonably recognize Medicare's interests and Medicare will deny coverage for all medical treatments and prescription drug expenses due to work-related injuries. The requirements are as follows: 1. Medicare Set-Aside Account - The WCMSA funds shall be placed in an interest bearing account, which is separate from any personal checking or savings account. A copy of the documents establishing the WCMSA account shall be sent to CMS at the following address within 30 days of disbursal of the Workers Compensation settlement. WCMSA Proposal/Final Settlement P.O. Box Oklahoma City, OK Note - If this case was submitted using the Workers Compensation Set-Aside Web Portal (WCMSAP), the documents must be attached and submitted to the case using the Web Portal. See the Case Documents section in the Web Portal case. 2. Distribution of funds from the Medicare Set-Aside Account - The funds in the WCMSA account shall be used solely for expenses related to medically necessary services or supplies or prescription drug expenses incurred for those medical needs related to or resulting from the workrelated injury, which would otherwise be reimbursable or paid for by Medicare. Funds in the WCMSA account shall not be used to pay for medical services or prescription drug expenses not covered by Medicare. Examples of services and items not covered by Medicare include (but are not limited to) travel expenses for medical appointments, acupuncture, routine dental care, eyeglasses, and hearing aids. Medicare covered services are available in the booklet "Medicare & You" which can be obtained from any local Social Security office. If there are any questions concerning what Medicare covers, please call Medicare ( ) or visit the Medicare websites at 3. Set-Aside Account Interest - All interest earned on the Medicare Set-Aside account will be allowed to accrue in the account and will be used solely for medical expenses and prescription drug expenses that would otherwise be covered by Medicare and for banking fees, mailing fees, or document-copying charges related to the account. 4. Reimbursement to Medicare - In the event CMS determines that Medicare has erroneously paid benefits, CMS (or its designated Contractor) shall have the right to seek and receive reimbursement of any such conditional payments or overpayments. 1/2

52 8/15/ Accounting Records - The administrator shall maintain accurate records of the distributions and expenditures from the WCMSA account. The records should indicate: the date of service; the name of the medical provider, supplier or pharmacy; the medical diagnosis, procedure, service, or item received; the amount paid for the medical expense or prescription drug expense; and the date of the payment. The administrator shall also retain a receipt or other evidence of each and every payment made from the WCMSA account. 6. Annual & Final Accountings and Delivery of Notices The administrator shall submit all required annual accountings of the WCMSA and notices to: NGHP PO BOX OKLAHOMA CITY, OK The annual accounting shall be submitted no later than 30 days after the close of the annual accounting period (which is the anniversary of the funding of the WCMSA from the Workers Compensation settlement). The administrator shall submit a final accounting within 60 days of the funds being depleted. The annual and final accountings will include the information set forth in paragraph 5 above. 7. Distributions Following Death of Beneficiary - In the event that the Medicare beneficiary dies before the funds in the WCMSA account are depleted, the account will continue to exist for payment of any outstanding bills for work-related injury medical expenses and prescription drug expenses that would otherwise be covered by Medicare. Any funds remaining in the WCMSA account after payment of all outstanding bills for work-related medical expenses and prescription drug expenses shall be paid to the beneficiary s estate or subject to State Law. 8. Inappropriate Set-Aside Account Expenditures - If, after the WCMSA account is depleted, the final accounting reveals that funds in the account were used to pay for items other than Medicare allowable expenses related to necessary services, supplies, or prescription drug expenses resulting from the work-related injury, Medicare will not pay for any future work-related medical expenses or prescription drug expenses until the funds have been restored to the account and properly exhausted. 2/2

53 8/15/ WORKERS COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT (WCMSA) REVIEW Case Control #: Medicare ID/SSN: Claimant's Name: Date of Injury: 04/29/1998 Diagnosis Code: Dx Code Dx Ind. Dx Description F332 ICD-10 Major depressive disorder, recurrent severe without psychotic features G43909 ICD-10 Migraine, unspecified, not intractable, without status migrainosus G894 ICD-10 Chronic pain syndrome M25511 ICD-10 Pain in right shoulder M25512 ICD-10 Pain in left shoulder M47812 ICD-10 Spondylosis without myelopathy or radiculopathy, cervical region M47817 ICD-10 Spondylosis without myelopathy or radiculopathy, lumbosacral region M5090 ICD-10 Cervical disc disorder, unspecified, unspecified cervical region M5412 ICD-10 Radiculopathy, cervical region M5416 ICD-10 Radiculopathy, lumbar region M5442 ICD-10 Lumbago with sciatica, left side R51 ICD-10 Headache Proposed Settlement Date (PSD): 11/17/2017 Date of Birth: 07/11/1967 Age at PSD: 50 Rated Age at PSD: 56 Life Expectancy: 26 yrs. Submitter: (408) EK HEALTH SERVICES, INC. 992 S. De Anza Blvd. Suite 101 San Jose, CA Claimant: WCMSA Administrator: [] SSA's record shows Representative Payee Proposed Future Medical WCMSA Amount: $169, Proposed Future Rx WCMSA Amount: $94, Total Proposed WCMSA: $264, Proposed Initial Deposit: $47, Total Settlement Amount: $380, Recommended WCMSA: $585, Pricing Method: Fee WC State: CALIFORNIA Recommended WCMSA Lump Sum [] or 1/4

54 8/15/ Recommended WCMSA Structured Payments: [X] Recommended Initial Deposit: $89, Annual Amount: $19, x 25 yrs. Anniversary Date: 11/17/2018 Type of Recommendation: Counter-Higher If not eligible for WCMSA, reason: Current Treatment Status for WC Injury or Disease (including past medical treatment): THE CLAIMANT SUSTAINED AN INDUSTRIAL INDUSTRIAL INJURY ON 4/29/1998 DUE TO A SLIP AND FALL ON A WAXED FLOOR. DIAGNOSES FOR THE INJURY INCLUDE CERVICALGIA, CERVICAL SPONDYLOSIS, CERVICAL DISC DISEASE, CERVICAL RADICULOPATHY, LUMBAGO, LUMBAR RADICULOPATHY, BILATERAL SHOULDER PAIN, CHRONIC PAIN SYNDROME, DEPRESSION, MIGRAINE HEADACHE, AND HEADACHE. INITIAL TREATMENT RECORDS WERE NOT AVAILABLE FOR REVIEW. RECORDS INDICATE THE CLAIMANT CAME UNDER THE CARE OF AN ORTHOPEDIC SURGEON AND UNDERWENT A RIGHT CARPAL TUNNEL RELEASE WITH ULNAR NERVE TRANSPOSITION. THE CLAIMANT CAME UNDER THE CARE OF A PAIN MANAGEMENT PHYSICIAN, AND A SPINAL CORD STIMULATOR WAS PLACED IN FEBRUARY THE CLAIMANT UNDERWENT A SPINAL CORD STIMULATOR REVISION ON 10/03/2012. THE CLAIMANT HAS CONTINUED TO TREAT REGULARLY WITH PAIN MANAGEMENT, UTILIZING PRESCRIPTION MEDICATION FOR ADDITIONAL SYMPTOM MANAGEMENT. THE PHYSICIAN HAS INDICATED THAT THE CLAIMANT NEEDS A PULSE GENERATOR REPLACEMENT AS THE BATTERY HAS DIED INTHE PRESENT IMPLANT AND IS NO LONGER FUNCTIONING PROPERLY. THE CLAIMANT HAS ALSO CONTINUED TO TREAT WITH A PSYCHIATRIST, ALSO USING PRESCRIPTION MEDICATION FOR MANAGEMENT OF THE PSYCHIATRIC SYMPTOMS. THE TREATING PHYSICIAN HAS RECOMMENDED LUMBAR EPIDURAL STEROID INJECTIONS. CONTINUED CONSERVATIVE MANAGEMENT IS RECOMMENDED. ANTICIPATED TREATMENT INCLUDES PHYSICIAN VISITS, DIAGNOSTIC STUDIES, PHYSICAL THERAPY, PSYCHOTHERAPY, INJECTIONS, SPINAL CORD STIMULATOR REPLACEMENT & REPROGRAMMING, LABORATORY TESTING, AND MEDICATION. Past Medical Treatment Unrelated to WC Injury or Its Co-Morbid Conditions: SCIATICA, BILATERAL UPPER EXTREMITY REGIONAL SYMPATHETIC DYSTROPHY, CHRONIC BACK AND NECK PAIN, GASTROEOPHAGEAL REFLUX DISEASE, ARTHRITIS, MOOD DISORDER. Future Treatment (for Medicare-covered items and reimbursable services for the WC injury only): FUTURE MEDICAL CARE INCLUDES PHYSICIAN VISITS, DIAGNOSTIC STUDIES, PHYSICAL THERAPY, INJECTIONS, SPINAL CORD STIMULATOR REPLACEMENT & REPROGRAMMING, LABORATORY TESTING, AND MEDICATIONS. The following chart summarizes the future medical treatment costs (exclusive of pharmacy items) that adequately protect Medicare's interests: Service Freq Every X Yrs # of Years Price Per Service Total COMPLETE BLOOD COUNT $10.59 $ COMPREHENSIVE METABO $14.39 $ VENIPUNCTURE $3.00 $78.00 URINE DRUG TEST $79.94 $2, PAIN MANAGEMENT PHYS $89.81 $28, PSYCHIATRIST OFFICE $89.81 $9, NEUROLOGIST OFFICE V $89.81 $4, ORTHOPEDIST OFFICE V $ $3, CERVICAL X-RAY $70.40 $ /4

55 8/15/ CERVICAL X-RAY $70.40 $ CERVICAL CT SCAN $ $ RIGHT SHOULDER X-RAY $45.52 $ RIGHT SHOULDER CT SC $ $ LEFT SHOULDER X-RAY $45.52 $ LEFT SHOULDER CT SCA $ $ LUMBAR X-RAY $77.19 $ LUMBAR CT SCAN $ $ LUMBAR TRANSFORAMINA $1, $3, KENALOG 80 MG FOR IN $15.08 $45.24 EMG/NCS UPPER EXTREM $ $ EMG/NCS LOWER EXTREM $ $ REPLACEMENT-SPINAL C $47, $143, REPROGRAMMING-SPINAL $ $11, PHYSICAL THERAPY $ $2, PSYCHOTHERAPY $ $2, Total: $217, Prescription Drugs (for Medicare-covered and reimbursable drugs for the WC injury only): MEDICATIONS ARE ALLOCATED PER THE MEDICAL RECORDS AND PHARMACY REPORTS. ARIPIPRAZOLE, HYDROXYZINE, BUPROPION, HYDROCODONE/ACETAMINOPHEN, TRAZODONE, FLUOXETINE, AND CARISOPRODOL WERE WAS INCLUDED INTO THE WCMSA AS THEY MET THE DEFINITION OF A MEDICAREPART D DRUG, WERE USED FOR A MEDICALLY ACCEPTABLE INDICATION, AND WERE FOUND TO BE PRESCRIBED FOR A DIAGNOSIS RELATED TO THE INJURY WITHIN THE MEDICAL/PHARMACY RECORDS. According to available documentation, this claimant is currently receiving the following drugs: TOPIRAMATE, ARIPIPRAZOLE, TRAZODONE HYDROCHLORIDE, FLUOXETINE HCL, CARISOPRODOL, ESOMEPRAZOLE MAGNESIUM, HYDROCODONE BITARTRATE- ACETAMINOPHE, GABAPENTIN, BUPROPION HCL XL, IBUPROFEN, HYDROXYZINE PAMOATE, The following chart summarizes the future prescription drug costs that adequately protect Medicare's interests: Drug National Drug Code Amount Per Unit (Dosage) Per Day Per Week Per Month # of Years Price Per Units HYDROXYZINE MG $0.22 $4, ARIPIPRAZOL MG $29.92 $280, HYDROCODONE MG-10 MG $0.64 $13, BUPROPION H MG $2.79 $26, CARISOPRODO MG $0.52 $9, ESOMEPRAZOL MG $0.99 $9, FLUOXETINE MG $0.05 $ GABAPENTIN MG $0.03 $ IBUPROFEN MG $0.28 $7, TRAZODONE H MG $0.49 $13, TOPIRAMATE MG $0.13 $2, Total: $368, Total Rationale for Decision: 3/4

56 8/15/ THE SUBMITTER'S RE-REVIEW REQUESTS THE FOLLOWING: 1.) REMOVE NORCO, SOMA, FLEXERIL AND PROZAC AS THEY HAVE BEEN DENIED BY UR AND IMR DETERMINATIONS. 2.) REMOVE WELLBUTRIN AS THE LAST FILL WAS 8/7/16. 3.) REMOVE VISTARIL AS IT WAS LAST FILLED ON 4/28/15 4.) REMOVE ABILIFY AS IT WAS LAST FILLED ON 12/3/15, AND 5.) REDUCE THE SPINAL CORD STIMULATOR (SCS) PRICING TO HISTORICAL PRICING. NEW EVIDENCE INCLUDES UR AND IMR STANDARDS. AFTER REVIEW OF THE NEW EVIDENCE AND EXISTING RECORDS, THERE HAS BEEN NO DOCUMENTATION OF RESOLUTION OF THE PSYCH CONDITION; NOR HAS THERE BEEN EVIDENCE OF DISCONTINUATION OF THE PSYCH DRUGS; THEREFORE, THE FOLLOWING DETERMINATIONS HAVE BEEN MADE: 1.) NORCO, SOMA, FLEXERIL AND PROZAC CONTINUE TO BE PRESCRIBED BY THE TREATING PHYSICIAN AND THE TREATING PHYSICIAN HAS NOT PROVIDED AN ALTERNATIVE TREATMENT PLAN; THEREFORE, THESE MEDICATIONS WILL NOT BE REMOVED. 2.) ACCORDING TO DR. WILSON`S (PSYCH) LETTER ON 6/8/2016, CLAIMANT CONTINUES TO TAKE WELLBUTRIN. WELLBUTRIN WAS CERTIFIED BY SEDGWICK VIA AN RFA ON 6/29/16; THEREFORE, THIS DRUG WILL NOT BE REMOVED. 3.) ACCORDING TO DR. WILSON`S (PSYCH) LETTER ON 6/8/2016, CLAIMANT CONTINUES TO TAKE VISTARIL. VISTARIL WAS CERTIFIED BY SEDGWICK VIA AN RFA ON 6/29/16; THEREFORE, VISTARIL WILL NOT BE REMOVED. 4.) ACCORDING TO DR. WILSON`S (PSYCH) LETTER ON 6/8/2016, CLAIMANT CONTINUES TO TAKE ABILIFY. ABILIFY WAS CERTIFIED BY SEDGWICK VIA AN RFA ON 6/29/16; THEREFORE, ABILIFY WILL NOT BE REMOVED. 5.) THE SCS PRICING WAS BASED ON THE WBMSA REFERENCE GUIDE'S RECOMMENDED CPT CODES AND THE MOST CURRENT CA WC FEE SCHEDULE AND WILL NOT BE CHANGED OR REDUCED. PLEASE REFER TO THE UPDATED 7/10/17 WCMSA REFERENCE GUIDE SECTION FOR EXPANDED STATE-SPECIFIC STATUTE GUIDELINES AND UPDATED DEFINED REQUIREMENTS FOR SCS PRICING. AN INITIAL DEPOSIT OF $89,343 INSTEAD OF THE SUBMITTER`S PROPOSED INITIAL DEPOSIT OF $47,595 WILL ADEQUATELY PROTECT MEDICARE`S INTEREST. 585,836 RECOMMENDED MSA, MINUS 47,969 A. COST OF 1ST SURG PROC (INCL PREP) 0 B. COST OF 1ST REPLACEMENT 0 C. RX INITIAL DEPOSIT 537,867 EQUALS REMAINING LIFE NEEDS 26 LIFE EXPECTANCY 20,687 REMAINING NEEDS/LE= ANNUAL NEEDS 2 TIMES TWO YEARS 41,374 D. EQUALS TWO YRS OF REMAINING NEEDS 89,343 CALCULATED INITIAL DEPOSIT = A+B+C+D The following chart summarizes the services and costs that adequately protect Medicare s interests: Subtotal Future Treatment: $217, Subtotal Prescription Drugs: $368, Grand Total: $585, /4

57 WORKERS COMPENSATION MEDICARE SET-ASIDE ARRANGEMENT (WCMSA) REVIEW Case Control #: WC Medicare ID/SSN: *****4507A Claimant's Name: Date of Injury: 02/18/2003 Diagnosis Code: Dx Code Dx Ind. Dx Description ICD-9 Mood disorder in conditions classified elsewhere ICD-9 Major depressive affective disorder, single episode, mild ICD-9 Chronic pain due to trauma 7202 ICD-9 Sacroiliitis, not elsewhere classified 7213 ICD-9 Lumbosacral spondylosis without myelopathy 7242 ICD-9 Lumbago Proposed Settlement Date (PSD): 11/18/2017 Age at PSD: 58 Rated Age at PSD: 67 Submitter: (877) RO BALTAYAN PROVIDIO MEDI SOLUTIONS 5613 DTC PARKWAY, SUITE 700 GREENWOOD VILLA, CO Claimant: JOHN DOE DORAVILLE, GA WCMSA Administrator: JOHN DOE DORAVILLE, GA [] SSA's record shows Representative Payee Date of Birth: 08/15/1959 Life Expectancy: 18 yrs.

58 Proposed Future Medical WCMSA Amount: $222, Proposed Future Rx WCMSA Amount: $323, Total Proposed WCMSA: $546, Proposed Initial Deposit: $96, Total Settlement Amount: $646, Recommended WCMSA: $237, Pricing Method: Fee WC State: GEORGIA Recommended WCMSA Lump Sum [] or Recommended WCMSA Structured Payments: [X] Recommended Initial Deposit: $42, Annual Amount: $11, x 17 yrs. Anniversary Date: 11/18/2018 Type of Recommendation: Counter-Lower If not eligible for WCMSA, reason: Current Treatment Status for WC Injury or Disease (including past medical treatment): THE CLAIMANT SUSTAINED INJURIES TO THE LUMBAR SPINE WHEN REMOVING TIRES FROM A TIRE RACK WHILE AT WORK AS A MECHANIC ON 2/18/2003. TREATMENT FOR THIS INJURY REMAINED CONSERVATIVE WITH EPIDURAL INJECTIONS, PHYSICAL THERAPY, TRIGGER POINT INJECTIONS,AND MEDICATIONS. THE CLAIMANT WAS ALSO DIAGNOSED AND TREATED FOR DEPRESSION RELATED TO THE WORK INJURIES. IN 2006 THE CLAIMANT UNDERWENT A SPINAL CORD STIMULATOR (SCS) IMPLANT THAT REMAINS IN PLACE. TREATMENT FOR THE LAST TWO YEARS HAS CONTINUEDTO REMAIN CONSERVATIVE WITH SCS MONITORING, MEDICATIONS, PHYSICAL/AQUA THERAPY AND FACET INJECTIONS. AS OF THE MOST RECENT SPINE SPECIALIST REPORT DATED 4/2017, MEDIAL BRANCH BLOCKS WERE ADMINISTERED AND MEDICATIONS WERE REFILLED AND MEDICATIONS WERE REFILLED. THE CLAIMANT ALSO REMAINS UNDER THE CARE OF A PSYCHIATRIST FOR ONGOING MANAGEMENT OF PSYCHIATRIC MEDICATIONS RELATED TO DEPRESSION. Past Medical Treatment Unrelated to WC Injury or Its Co-Morbid Conditions: DIABETES Future Treatment (for Medicare-covered items and reimbursable services for the WC injury only):

59 BASED ON THE MEDICAL RECORDS PROVIDED, THE FOLLOWING MEDICAL SERVICES ARE INCLUDED N THE WCMSA. The following chart summarizes the future medical treatment costs (exclusive of pharmacy items) that adequately protect Medicare's interests: Service Freq Every X Yrs # of Years Price Per Service Total PSYCHOTHERAPY VISITS $ $3, SCS REPROGRAMMING $ $7, X-RAY LUMBAR SPINE $ $ PAIN MANAGEMENT VISI $ $17, VENIPUNCTURE $4.95 $89.10 CT LUMBAR SPINE $ $2, BLOOD TEST, COMPREHE $19.58 $ COMPLETE BLOOD CELL $14.41 $ PSYCHIATRIC VISITS $ $8, DEPO-MEDROL (J1030) $11.53 $34.59 KENALOG (J3301) $7.54 $22.62 ORTHOPEDIC VISITS $ $2, SCS /REPLACEMENT $18, $36, SI INJECTIONS $1, $5, MEDIAL BRANCH BLOCKS $2, $7, PHYSICAL THERAPY $ $3, URINE DRUG SCREEN $60.49 $1, EMG/NCS $ $ Total: $97, Prescription Drugs (for Medicare-covered and reimbursable drugs for the WC injury only): OXYCONTIN WAS PRICED AS THE BRAND VERSION AS THE PHARMACY RECORDS REFLECT BRAND USAGE. According to available documentation, this claimant is currently receiving the following drugs: ACETAMINOPHEN/HYDROCODONE BITARTRAT, OXYCONTIN, ZOLPIDEM TARTRATE, BUPROPION HYDROCHLORIDE, ARIPIPRAZOLE, CYCLOBENZAPRINE HYDROCHLORIDE, DULOXETINE HYDROCHLORIDE, TRAZODONE HYDROCHLORIDE, The following chart summarizes the future prescription drug costs that adequately protect Medicare's interests: Drug National Drug Amount Per Unit Per Per Per # of Price Total

60 Code (Dosage) Day Week Month Years Per Units TRAZODONE H MG $0.23 $1, DULOXETINE MG $1.16 $15, BUPROPION H MG $2.79 $18, ZOLPIDEM TA MG $0.10 $ CYCLOBENZAP MG $0.03 $ ACETAMINOPH MG-7.5 MG $0.61 $3, ARIPIPRAZOL MG $0.45 $2, OXYCONTIN MG $7.51 $97, Total: $139, Rationale for Decision: INSTEAD OF THE SUBMITTER`S PROPOSED SET-ASIDE, CMS HAS DETERMINED THAT A DIFFERENT SET-ASIDE AMOUNT IS NECESSARY TO PROTECT MEDICARE`S INTEREST FOR THE FOLLOWING REASONS: MEDICAL SERVICES AND PRESCRIPTION MEDICATION PRICING IS LOWER THAN PRICING USED IN THE PROPOSAL. AN INITIAL DEPOSIT OF $42,486 INSTEAD OF THE SUBMITTER`S PROPOSED INITIAL DEPOSIT OF $96,307 WILL ADEQUATELY PROTECT MEDICARE`S INTEREST. 237,829 RECOMMENDED MSA, MINUS 18,068 A. COST OF 1ST SURG PROC (INCL PREP) 0 B. COST OF 1ST REPLACEMENT 0 C. RX INITIAL DEPOSIT 219,761 EQUALS REMAINING LIFE NEEDS 18 LIFE EXPECTANCY 12,209 REMAINING NEEDS/LE= ANNUAL NEEDS 2 TIMES TWO YEARS 24,418 D. EQUALS TWO YRS OF REMAINING NEEDS 42,486 CALCULATED INITIAL DEPOSIT = A+B+C+D The following chart summarizes the services and costs that adequately protect Medicare s interests: Subtotal Future Treatment: $97, Subtotal Prescription Drugs: $139, Grand Total: $237,830.00

61 Data Development Committee 2017 MEDICATIONS Drug Name Strength Medicare Set- Aside CMS Submission Quality Improvement Data Analytics Please return completed form to or Submission Date Submission Submitted NDC Submitted AWP CMS Response Date CMS RESPONSE CMS Regional Office CMS documente d NDC CMS documented AWP (per unit) Hydro/APAP 7.5/325 8/22/ $0.61 9/8/17 Atlanta Same $0.61 Oxycontin 15mg 5/11/ $5.41 5/18/16 Atlanta Same $5.41 Oxycodone 10mg 5/11/ $0.62 5/18/16 Atlanta Same $0.62 Hydroco/APAP 10/325mg 9/4/ $0.64 9/24/15 Atlanta Same $0.64 Oxyco/APAP 10/325mg 8/8/ $3.37 8/21/17 Atlanta Same $3.37 Suboxone 8/2mg 8/10/ $8.86 8/24/17 Atlanta Same $8.86 Hydroco/APAP 5/325mg 1/19/ $0.40 2/23/17 Atlanta Same $0.40 APAP/codeine 300/30mg 4/14/ $0.28 4/26/16 Atlanta Same $0.28 Fentanyl patch 25mcg 1/18/ $ /26/16 Atlanta Same $13.00 Hydroco/APAP 7.5/325mg 12/14/ $ /23/15 Atlanta Same $0.61 Oxyco/APAP 10/325mg 10/21/ $ /12/15 Atlanta Same $3.37 Methadone 10mg 6/17/ $0.14 7/14/15 Same $0.14 Hydro/APAP 5/325mg 6/29/ $0.45 7/13/15 Atlanta Same $0.45 CMS Response turn around time #Days CMS Counter- Lower based on exclusion of these medicati

62 ANALYSIS Comments 12 year LE - 12 x annually 18 year LE - 12 x annually 18 year LE - 12 x annually 24 year LE - 12 x annually 16 year LE - 12 x annually 14 year LE - 12 x annually 18 year LE - 12 x annually 18 year LE - 12 x annually 23 year LE - 12 x annually 21 year LE - 12 x annually 26 year LE - 12 x annually 34 year LE - 12 x annually - Kansas City RO 8 year LE - 12 x annually

63 Data Development Committee 2017 MEDICATIONS Drug Name Strength Medicare Set- Aside CMS Submission Quality Improvement Data Analytics Please return completed form to or Submission Date Submission Submitted NDC Submitted AWP CMS Response Date CMS RESPONSE CMS Regional Office CMS documente d NDC CMS documented AWP (per unit) Opana ER 30mg 6/10/ $ /19/15 Atlanta Same $11.10 Hydro/APAP 10/325mg 4/18/ $0.52 5/4/15 Atlanta Same $0.52 Hydro/APAP 10/325mg 1/20/ $0.52 1/26/15 Atlanta Same $0.52 Percocet 5/325mg 1/29/16 San Francisco Suboxone 8.2/4mg 3/4/16 San Francisco Oxycodone 5mg 3/4/16 San Francisco Tramadol 50mg 6/29/16 San Francisco Tramadol 50mg 8/10/16 San Francisco Percocet 325/5mg 8/10/16 San Francisco Hydrocodone/APAP 7.5/325mg 8/19/16 San Francisco Hydrocodone/APAP 7.5/325mg 8/23/16 San Francisco Percocet 7.5/325mg 8/23/16 San Francisco Acetaminophen/oxycodone 325/10mg 9/16/16 San Francisco CMS Response turn around time #Days CMS Counter- Lower based on exclusion of these medicati

64 ANALYSIS Comments 33 year LE - 12 x annually 14 year LE - 12 x annually 25 year LE - 12 x annually Included #180 for 26 years life expectancy Included #60 for 21 years life expectancy Included #90 for 27 years life expectancy Included #90 for 14 years life expectancy Included #180 for 18 years life expectancy Included #60 for 18 years life expectancy Included #150 for 21 years life expectancy Included #120 for 22 years life expectancy Included #15 for 22 years life expectancy Included #30 for 20 years life expectancy

65 Data Development Committee 2017 MEDICATIONS Drug Name Strength Medicare Set- Aside CMS Submission Quality Improvement Data Analytics Please return completed form to or Submission Date Submission Submitted NDC Submitted AWP CMS Response Date CMS RESPONSE CMS Regional Office Hydrocodone/APAP 10/325mg 12/27/16 San Francisco Oxycodone 5mg 2/1/17 San Francisco MS Contin 15mg 2/22/17 San Francisco Morphine IR 15mg 2/22/17 San Francisco MS Contin 15mg 5/26/17 San Francisco Morphine IR 15mg 5/26/17 San Francisco Hydromorphone 4mg/2mg 3/1/17 San Francisco Hydrocodone/APAP 300/5mg 5/16/17 San Francisco Hydrocodone/APAP 325/10mg 6/27/17 San Francisco Hydrocodone/APAP 352/5mg 7/24/17 San Francisco CMS documente d NDC CMS documented AWP (per unit) CMS Response turn around time #Days CMS Counter- Lower based on exclusion of these medicati