Medicare Set Aside (MSA) Rules
Medicare Set Aside (MSA) rules confuse many people.
Recently, I posted on Medicare Set Asides (MSA or WCMSA). I received quite a few questions on how to quickly tell if MSA’s are necessary or not or Workers Comp files. I have seen flowcharts online that are not correct – one even by an MSA provider. The following is a quick synopsis.
In settlements where the future medical is going to be closed as part of the settlement the following must be considered:
CLASS I BENEFICIARY
Claimant is considered a Class I Medicare beneficiary if:
a) Claimant is 65 years or older;
b) Claimant has been on SSDI for 24 months or longer; or
c) Claimant has End Stage Renal Disease (ESRD)
As such, regardless of settlement value and including “compromise” settlements, you must consider Medicare’s interests. Medicare will need to review all Class I beneficiary settlements valued at $25,000 or greater. Class I beneficiary settlements below $25,000 in value do not require submission to and approval from Medicare. You are still required to consider Medicare’s interests and include future Medicare related medical costs in an allocation within the settlement.
CLASS II BENEFICIARY with Settlement values greater than $250,000
Medicare approval is needed when settlement value is $250,000 or higher AND where an individual has a “reasonable expectation” of Medicare enrollment within 30 months. Situations that constitute “reasonable expectation” include but are not limited to:
a) Claimant is on SSDI but not yet Medicare eligible;
b) Claimant has applied for Social Security Disability Benefits;
c) Claimant has been denied Social Security Disability Benefits but anticipates appealing that decision or is in the process of appealing and/or re-filing;
e) Claimant is 62 years and 6 months old (i.e., may be eligible for Medicare based upon his/her age within 30 months);
f) Claimant has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.
Note: The Social Security Administration may use the following indicators when approving a claimant for SSDI benefits: Claimant has been deemed permanently and totally disabled; or Provider states that claimant cannot return to any reasonable gainful employment for a period of 12 months or longer.
CLASS II BENEFICIARY with Settlement value less than $250,000
Although Medicare approval is not needed for settlement value of under $250,000, when an individual does not have a “reasonable expectation” of Medicare enrollment within 30 months most insurers, self insurer, third party adjusters, and attorneys require a Medicare Allocation be completed for all cases greater than $25,000 to be certain Medicare’s interests are considered for future medical associated with a Liability or Workers Compensation settlement.
An appropriate portion of the total settlement needs to be identified as the Medicare Allocation. Additional services such as Structured Settlement, Custodial Medical and Indemnity Accounting, and Special Needs Trusts should be considered for complete administration, and to assure the client that the case will remain closed and appropriately managed according to the terms of settlement.
CLASS II BENEFICIARY with Settlement value less than $250,000
Although Medicare approval is not needed for settlement value of under $250,000, when an individual does not have a “reasonable expectation” of Medicare enrollment within 30 months most insurers, self insurer, third party adjusters, and attorneys require a Medicare Allocation be completed for all cases greater than $25,000 to be certain Medicare’s interests are considered for future medical associated with a Liability or Workers Compensation settlement.
An appropriate portion of the total settlement needs to be identified as the Medicare Allocation. Additional services such as Structured Settlement, Custodial Medical and Indemnity Accounting, and Special Needs Trusts should be considered for complete administration, and to assure the client that the case will remain closed and appropriately managed according to the terms of settlement.
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