"When Credibility is Critical"
p: 406.721.9320 800.322.9320
MEDICARE SET-ASIDE (MSA) ARRANGEMENTS & ALLOCATIONS: WORKERS' COMPENSATION (WC)
Purpose
To reasonably consider Medicare's interests in workers' compensation settlements.
- Accomplished through the use of an MSA
- A portion of settlement is 'set-aside' to cover future work-related medical expenses
The Medicare Secondary Payer (MSP) Act (42 U.S.C. 1395y[b][2]) prohibits Medicare from paying a Medicare beneficiary's medical expenses when payment "has been made or can reasonably be expected to be made under a workmen's compensation plan . . ."
Consideration of Medicare's interests is accomplished:
- Through the use of a 'Medicare Set-Aside Arrangement' whereby,
- A portion of the settlement proceeds are allocated ('set-aside') to cover future work-related expenses
Once the money set aside for that purpose has been exhausted, Medicare becomes responsible for paying for all Medicare-covered expenses, even if they are work related.
The Centers for Medicare and Medicaid Services (CMS) require submission and review of the settlement agreement and an MSA whenever a WC settlement meets the following review criteria:
- Class I: The claimant is currently eligible for Medicare and total uncommuted value* of WC settlement exceeds $25,000.00; or,
- Class II: The claimant is reasonably expected** to become eligible for Medicare within 30 months of a WC settlement with total uncommuted value of more than $250,000.00
*Total uncommuted value of settlement includes past and future medicals, indemnity, attorney's fees and costs, and any Medicare overpayments. If a structured settlement, count the total of all expected payments
**Reasonable expectation of Medicare eligibility within 30 months = age 62.5; currently receiving SSDIB; has applied or plans to apply for SSDIB; is appealing denial of SSDIB; has diagnosis of ESRD or ALS
This page was last updated: March 6, 2012
© Copyright 2011-2012 Life Care Services
® All Rights Reserved.
