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Medicare Set-Aside Arrangement
When Medicare announced strict enforcement
of the Medicare Secondary Payer Statute in July of 2001, few
companies knew what a Medicare Set-Aside Arrangement was.
Since that time, many new faces have emerged touting their
Medicare compliance solutions, but only one reliable and consistent
resource has been serving Workers’ Compensation carriers,
self-insured employers, third-party administrators, structure
settlement brokers, and attorneys since the very beginning.
Gould & Lamb, LLC offers the only complete solution since
the very beginning. We have a 100% approval rate on our submissions
to CMS and 98% are approved after the first review by CMS
officials. Since 1999, we have completed thousands of allocations
nationwide.
Just what is a Medicare Set-Aside Arrangement?
History
The Medicare Secondary Payer (MSP) statute
has been around since 1980, but the concept of a Medicare
Set-Aside Trust was not adopted by The Center for Medicare
& Medicaid Services (CMS) until 1995. The basic premise of
the MSP is that Medicare will remain a “secondary payer”
if a “primary payer” exists. While the statute applies
to Liability, FECA, Black Lung and Longshore claims, Workers’
Compensation cases became the focus of CMS attention, in part,
due to a General Account Office (GAO) report to Congressional
Committees in May of 2001. The report found that federal benefit
programs, such as Social Security and Medicare, were losing
potentially billions of dollars per year as a result of payment
errors from Workers’ Compensation cases. To quickly combat
these obvious concerns, CMS released the July 2001 Policy
Memorandum that initiated the MSA Arrangement process as it
is known today.
According to the Centers for Medicare and
Medicaid Services’ July 11, 2001 Policy Memorandum and
subsequent FAQs posted since then, CMS requires that certain
Workers’ Compensation settlements, those seeking to limit
or close future medical benefits with a qualified claimant,
obtain CMS Regional Office approval of the settlement and
MSA Allocation. An MSA Allocation is simply an accurate projection
of the lifetime future medical costs covered by Medicare.
Qualified claimants are often referred to as Class I and Class
II claimants or beneficiaries and are determined as follows:
- CLASS I – The claimant is
a Medicare Beneficiary, regardless of the settlement amount
- CLASS II – The claimant must
pass a two-prong test:
- “Reasonable Expectation”
test:
- Does the claimant have a reasonable
expectation of Medicare enrollment within 30 months
from settlement
- Has the claimant applied and/or awarded
Social Security Disability benefits?
- Has the claimant been declined Social
Security Disability benefits, but is in the process
of appealing and/or refiling for Social Security Disability
benefits?
- Is the claimant 62 ½ years
of age or older?
- Does the claimant have End Stage
Renal Disease (ESRD) but does not yet qualify for Medicare?
and
The formation of a Medicare Set-Aside Arrangement
is a complex and challenging issue to deal with. Inexperience
and mishandling lead to increased settlement costs, inappropriate
Medicare Set-Aside allocation amounts, and significant time
delays when obtaining approval for the allocation amount through
Medicare. We assist clients with the many facets and complexities
of settling a Workers’ Compensation claim. You can rely
on our experience to help protect your interests from the
filing of the initial claim through the settlement of the
case.
Online
Referral Form
Manual
Referral Form
Claimant
General Release Form
SS
Release Form
Benefits
FAQ's
If you have any questions please contact the Gould & Lamb Client Services Department at (866) 672-3453 (MSA-FILE) between 8:30 am and 7:00pm EST Monday through Friday.
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