Our firm assists counsel, insurance carriers, self-insured employers, and third party administrators nationwide in settling workers’ compensation cases and special needs trusts while preserving the injured worker or plaintiff’s Medicare eligibility. We are committed to bringing our clients timely, accurate and affordable services. We know your concerns and are committed to meeting them.
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- Medicare Set Aside Arrangements
- Medical Cost Projection
- CMS Submission of MSA
- Medicare Conditional Payment Search
- Structured Settlement Analysis/Implementation
- Professional Administration
Price List – Upon request
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Settlements Greater than $250,000 where the Claimant is “Reasonably Expected to Become a Medicare Beneficiary”
An individual has a “reasonable expectation” of Medicare enrollment if any of the following situations apply:
(a) The individual has applied for Social Security Disability Benefits;
(b) The individual has been denied Social Security Disability Benefits but anticipates appealing that decision;
(c) The individual is in the process of appealing and/or re-filing for Social Security Disability Benefits;
(d) The individual is 62 years and 6 months old (i.e., may be eligible for Medicare based upon his/her age within 30 months); or
(e) The individual has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.
To the extent a WC settlement meets both of the criteria (i.e., the settlement is greater than $250,000 AND the claimant is reasonably expected to become a Medicare beneficiary within 30 months of the settlement date), then a CMS-approved Medicare set-aside arrangement is appropriate.
CMS Review Threshold in Workers Compensation Cases
A WCMSA may be submitted to CMS for review in the following situations:
- The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; OR
- The claimant has a “reasonable expectation” of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.
Current Medicare Beneficiaries
Injured individuals who are already Medicare beneficiaries must always consider Medicare’s interests prior to settling their WC claim regardless of whether or not the total settlement amount exceeds $250,000. That is, ALL WC PAYMENTS regardless of amount must be considered for current Medicare beneficiaries.
However, CMS no longer reviews new WCMSA proposals for Medicare beneficiaries where the “total settlement amount” is $25,000 or less (i.e., low dollar threshold Medicare beneficiaries). In order to increase efficiencies in our process, and based on available statistics, CMS instituted this workload review threshold. However, CMS wishes to stress that this is a CMS workload review threshold and not a substantive dollar or “safe harbor” threshold. Medicare beneficiaries must still consider Medicare’s interests in all WC cases and ensures that Medicare is secondary to WC in such cases. In other words, if the total settlement amount is $25,000 or less, the parties to the settlement are still required to consider Medicare’s interests. The recommended method to protect Medicare’s interests is to enter into a Medicare Set Aside arrangement to protect Medicare’s interests, even though CMS will not review the proposal. (Ref: 7/11/05 Memo Q1 and 2)