The Medicare Set-Aside process consists of three main components, the MSA allocation, the method of funding and the method of administration. Delta settlements streamlines the process by providing thorough MSA allocations as well as expert funding and administration advice to plaintiff attorneys and their clients. Our Medicare Set-Aside (MSA) team is dedicated to understanding the medical issues in your case. Our experienced advisors provide one-on-one consultations and constant status updates throughout the MSA process.
General Information Surrounding the Medicare Set-Aside Process:
Medicare is a Federal health insurance program for people age 65 or older, certain younger people with disabilities, and people with qualifying End-Stage Renal Disease. Medicare is governed by the Center for Medicare and Medicaid Services (CMS). Pursuant to the Medicare Secondary Payer Laws, Medicare pays second when another primary source of coverage is available with respect to workers’ compensation, liability insurance, self-insurance and no-fault insurance. When a workers’ compensation or liability settlement is intended to compensate an individual for future medical expenses, Medicare will not allow the settlement to shift the burden of medical expenses from the primary payer to Medicare. Therefore, Medicare’s interests must be protected in any settlement that closes or limited future medical benefits for qualified beneficiaries. The MSA is the recommended method of protecting Medicare’s interests.
A conditional payment allows a Medicare beneficiary to receive timely treatment for Medicare covered services, pending payment from a primary plan. The payment for medical treatment is made by Medicare on the condition that Medicare will receive reimbursement. Those responsible for reimbursement include the primary payer, or anyone who received primary payment, including a beneficiary, provider, supplier, physician, attorney, State agency or private insurer.
A Medicare Set-Aside (MSA) is a projection of the future injury related medical costs that would ordinarily be covered by Medicare if another primary payer did not exist. The purpose of the MSA is to protect Medicare’s interests and preserve the Medicare benefits of an injured claimant. An MSA may be necessary when a settlement closes or limits future medical benefits for qualified beneficiaries. Qualified beneficiaries are those persons currently receiving Medicare or those reasonably likely of Medicare enrollment within 30 months of the date of settlement. Many factors must be taken into account in order to determine the MSA allocation. The MSA is the CMS preferred method of setting aside funds as it offers the greatest level of protection for Medicare and Medicare beneficiaries.
Currently, CMS has established review thresholds for Workers’ Compensation cases only. However, cases that do not meet the threshold for review must still protect Medicare’s interests. The current monetary review thresholds for Workers’ Compensation settlements are when a claimant is a Medicare beneficiary at the time of settlement and the total settlement amount is $25,000.00 or greater or claimant is “reasonably likely” to be on Medicare within 30 months of the date of settlement and the settlement amount is $250,000.00 or greater. CMS has emphasized that the review thresholds can be changed at any time.
The MSA can be funded via lump sum or annuity. With lump sum funding, the entire amount of the MSA is funded all at once. With an annuity, the MSA is funded over a series of periodic payments. There are numerous benefits to using an annuity as the method of funding, including a guaranteed source of income as well as tax benefits. Regardless of the method of funding, the MSA funds must be kept in a separate interest bearing account and can only be used to pay for Medicare covered services related to the injury.
The MSA may be self-administered or professionally administered. Professional administration must be utilized with legally incompetent claimants. CMS maintains strict guidelines for MSA funds and a beneficiary could lose his or her Medicare benefits for improper expenditure. Therefore, it is advisable to utilize the services of a Professional Administrator.
Please contact our office with questions surrounding the Medicare Set-Aside process. To request an MSA allocation, please fill out the MSA application and submit the requested documentation. The projected turn-around time for MSA completion is 14 days or less. Rush services are also available upon request.