Getting a Medicare Set-Aside (MSA) proposal reviewed and approved by the Centers for Medicare & Medicaid Services (CMS) generally takes about 30 to 60 days on average once the proposal has been submitted to them. However, the overall timeline for an MSA can vary significantly depending on several factors, including the complexity of the case and the completeness of documentation.
Understanding the Medicare Set-Aside (MSA) Process
A Medicare Set-Aside (MSA) is a financial arrangement that allocates a portion of a personal injury or workers' compensation settlement to cover future medical expenses related to the injury that would otherwise be covered by Medicare. Its primary purpose is to protect Medicare's interests and ensure that settlement funds are appropriately used for injury-related care before Medicare pays for those services.
Before a proposal can even be submitted to CMS for review, several preliminary steps must be completed:
- Data Collection: Gathering all relevant medical records, billing statements, prescription records, and settlement documents.
- Medical Review and Analysis: A professional reviews the medical history to determine future medical needs and associated costs.
- MSA Report Generation: A detailed report is drafted, outlining the recommended allocation amount for future medical care and prescription drugs.
The CMS Approval Timeline
The 30 to 60-day average timeline specifically refers to the period CMS takes to review and provide a determination on a submitted MSA proposal. This phase begins after the MSA report has been fully prepared and submitted through the appropriate channels.
Several factors can influence how long CMS takes for its review:
- Completeness and Accuracy: Submitting a comprehensive and accurate MSA proposal with all required medical records and settlement documentation can prevent delays.
- Case Complexity: Cases involving multiple injuries, extensive medical histories, or significant future medical needs may require more detailed scrutiny from CMS, potentially extending the review period.
- CMS Workload: Like any government agency, CMS's processing times can fluctuate based on their current workload and staffing levels.
- Requests for Additional Information (RFIs): If CMS requires further clarification or additional documents, they will issue an RFI. Responding to these promptly is crucial, as delays can extend the overall timeline significantly.
- Re-review Requests: In some instances, if an MSA is returned with modifications or requires an appeal, it will necessitate another review cycle, adding more time.
Key Stages and Estimated Durations
The entire MSA process, from initial preparation to final CMS approval, can span several months. Here’s a breakdown of typical stages:
| Stage | Estimated Duration | Description |
|---|---|---|
| Initial MSA Report Preparation | 2-6 weeks (variable) | Gathering records, comprehensive medical review, cost projection, and drafting the detailed MSA report. |
| Client/Attorney Review & Negotiation | 1-4 weeks (variable) | Internal review of the drafted MSA report, potential negotiations with the settling parties. |
| CMS Submission & Review | 30-60 days (average) | Official review by the Centers for Medicare & Medicaid Services once submitted. |
| RFI Responses/Re-review (if needed) | Additional 2-8 weeks+ | Time taken to respond to CMS's requests for more information or for re-submission after modifications. |
Expediting the MSA Process
While some aspects of the MSA timeline are beyond direct control, there are practical steps that can help streamline the process:
- Provide Complete Documentation: Ensure all relevant medical records, settlement agreements, and other necessary documents are accurate, up-to-date, and submitted with the initial request. Missing or inaccurate information is a primary cause of delays.
- Work with Experienced Professionals: Engaging a reputable MSA allocation company or legal professional specializing in MSAs can ensure the report is prepared correctly and submitted efficiently, minimizing the chances of CMS rejections or RFIs.
- Promptly Respond to RFIs: If CMS requests additional information, respond as quickly and thoroughly as possible. Delays in responding directly prolong the approval process.
- Understand the Requirements: Familiarize yourself with CMS's MSA review thresholds and guidelines to ensure the case meets the necessary criteria for submission. More information can be found on the CMS website.
Why is a CMS-Approved MSA Important?
Obtaining CMS approval for an MSA provides several critical benefits. It offers "safe harbor" from future medical claim denials by Medicare related to the injury. Without a CMS-approved MSA in cases meeting specific thresholds, Medicare may deny payment for future injury-related medical treatment, or even seek reimbursement from the settlement funds if Medicare has previously paid for services that should have been covered by the settlement. This can lead to significant financial liabilities for the injured individual.
