Medicare Set-Aside Allocations
All parties in a Worker's Compensation (WC) case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare's interest when resolving WC cases that include future medical expenses. Although the statute has been in place since the 1980's, Center for Medicare Services (CMS) has increased efforts to obtain set aside arrangements for qualified settlements.
The recommended method to protect Medicare's interests is a Worker's Compensation Medicare Set-Aside Arrangement (MSA), which allocates a portion of the WC settlement for future medical expenses.
A Medicare Set-Aside arrangement should be considered:
• If the injured party is currently on Medicare (through Social Security Disability or retirement)
OR
• If there is a reasonable expectation that the injured party is going to be on Medicare (through Social Security Disability or retirement) within 30 months of date and settlement AND the amount of settlement is $250,000 or more, inclusive of attorney fees.
A Medicare Set-Aside arrangement is a document developed to identify future care needs and the associated costs related to an individual's WC injury. The document specifies the Medicare eligible services that are covered by the WC settlement and "set aside" a fund to cover these future expenses. The future care costs are paid out of the fund according to the workers compensation fee schedule in the state of jurisdiction (or by the method used in the arrangement).
Once the CMS determined set aside amount is exhausted and accurately accounted for by CMS, Medicare becomes the primary payer of the Medicare covered expenses for the related injury.
Components of a Medicare Set-Aside Plan:
• Review of medical and billing records
• Verification of Social Security/Medicare benefits
• Secure treatment recommendations from providers
• Review treatment against applicable clinical guidelines and standards of care
• Identify future medical needs, Medicare coverable services, and Medicare charges within the state of jurisdiction