ABSTRACT
Contents Objectives ................................................................................................................................213 Medicare Set-Aside Arrangements ............................................................................................214 When is an MSA Allocation Required?.....................................................................................215 Review Th reshold .....................................................................................................................215 Historical Perspective: Legislation .............................................................................................215 Medicare Benefi ciaries and Settlement Amount ........................................................................217 Th e Set-Aside Process ...............................................................................................................217 Consequences of Noncompliance .............................................................................................218 Life Care Planning and MSA Arrangements .............................................................................219 Commutations and Compromise .............................................................................................219 When is the Claimant Not Yet Eligible for Medicare ............................................................... 220 Review Th reshold .................................................................................................................... 220 MSA Trusts ............................................................................................................................. 220 Regional Offi ces ...................................................................................................................... 220 Criteria .....................................................................................................................................221 CMS Review of the MSA Allocation/Arrangement ..................................................................221 Th ird-Party Liability ................................................................................................................ 222 When is a Set-Aside Unnecessary? ........................................................................................... 222 What is Necessary to Secure Medicare’s Approval? ................................................................... 223 What Supporting Documentation is Required? ....................................................................... 223 Administration of the MSA ..................................................................................................... 223 Funding of the MSA Account ................................................................................................. 223 Appeals .................................................................................................................................... 224
Review Th reshold for MSA Allocations ................................................................................... 224 Compromised Settlement ........................................................................................................ 224 Commutation Settlement ........................................................................................................ 224 Consideration of Medicare’s Interest ........................................................................................ 225 Settlement Agreement ............................................................................................................. 225 WC Settlements with MSA Arrangements: Conditional/Lien Payment Issues ......................... 226 Components of an MSA Arrangement .................................................................................... 226 WC Fee Schedule .................................................................................................................... 227
Allocation Amount ......................................................................................................... 227 Review of Medical Records ................................................................................. 227 Review of the Medical Payment History .............................................................. 227 Physician Recommendations ............................................................................... 227 Standards of Care ................................................................................................ 228 Life Expectancy ................................................................................................... 228
Method of Funding ........................................................................................................ 228 Lump Sum Payment ........................................................................................... 228 Annuity ............................................................................................................... 228
Method of Administering ............................................................................................... 228 Self-Administration ............................................................................................. 228 Professional Administration ................................................................................ 229
Distribution of Funds .............................................................................................................. 229 Annual Account Summary and Administrative Requirements ................................................. 229 WC Data Sharing Agreements................................................................................................. 230 Proposal Format ...................................................................................................................... 230 MSA Cost Projection Report Guidelines ................................................................................. 230 Submission Materials............................................................................................................... 230 Case Example of an MSA Cost Projection Report ................................................................... 230 Sample MSA Cost Allocation Report .......................................................................................231 Introduction .............................................................................................................................231 Entitlement and COBC Contact Information ..........................................................................231 Life Expectancy Issues ............................................................................................................. 232 Description of Injury and Initial Treatment ............................................................................. 232
Description of Injury ...................................................................................................... 232 Key Medical Treatment Events........................................................................................ 232 Present Status and Current Treatment ............................................................................. 233 Future Medical Needs Typically Covered by Medicare .................................................... 233 Medicare-Covered Items ................................................................................................. 233
Physician Visits ................................................................................................... 233 Laboratory ...........................................................................................................233 Diagnostic Studies ................................................................................................233 Physical Th erapy ................................................................................................. 234 Surgery ................................................................................................................ 234
Medications .................................................................................................................... 234 Prescription Medications/Part D Formulary Coverage ......................................... 234
Future Medical Needs Typically Not Covered by Medicare ............................................. 234 Complications ......................................................................................................................... 234 Proposed Consideration of Medicare’s Interests ....................................................................... 234
Objectives Discuss the fi nancial impact of a Medicare set-aside (MSA) on the settlement ◾ Discuss how the injured workers current medical treatment will impact an MSA ◾ Identify the diff erences between Medicare and Medicaid ◾ Identify the components of an MSA ◾ Describe the type of injured worker who might require a formal MSA ◾
Submission of MSA Allocation to CMS for Approval ......................................................235 Medicare ........................................................................................................................ 236 Medicare Coverage Database .......................................................................................... 236 Medicare Guidelines ....................................................................................................... 236 MSA Sample Submission as per CMS ............................................................................ 236 MSA Submission Checklist ............................................................................................ 237 Social Security Website ................................................................................................... 237 CDC Life Table .............................................................................................................. 237 Medicare Regulations ..................................................................................................... 237 Source of Additional Information ................................................................................... 237
National Alliance of MSA Professionals ............................................................... 237 Test Questions ......................................................................................................................... 238 Appendix A: Overview of WC ................................................................................................. 240
Who is Eligible for WC Benefi ts ..................................................................................... 240 WC is State-Specifi c in Statutes ...................................................................................... 240
Appendix B: Overview of Medicare ......................................................................................... 240 Introduction ................................................................................................................... 240 Medicare Eligibility and Coverage ...................................................................................241
