Medicare Set Aside Myths

Friday, July 29, 2005 | 0

CMS has issued a new FAQ dated July 11, 2005 which provides its best clarification of several key issues relating to Medicare set-aside allocations in workers' compensation cases.

First, Question #1 specifically confirms that the review thresholds set up by CMS (i.e., $250,000 total settlement and Medicare eligibility within 30 months) are workload thresholds only. There is no "safe harbor," as CMS states, for compliance with the Medicare Secondary Payer (MSP) statute.

Thus, while CMS' review of files outside these thresholds may not be necessary, consideration of Medicare's interests by virtue of including an MSA allocation in a given settlement is still appropriate as the MSP statute still applies.

Other issues of note include Question #8 in which CMS confirms that a workers' compensation Medicare set-aside ("WCMSA") allocation is still necessary when the claimant is covered under alternate coverage plans, and Question #11 in which CMS confirms they do not compromise or reduce future medical expenses in a Workers' Compensation claim (i.e., percentage method).

There will always be issues like those outlined in Question #12 (cases on which CMS approves an alternate MSA allocation) and Question #15 (CMS' statement regarding non-Medicare covered items that become covered in years subsequent to final settlement) which need to be challenged.

When you face one of these issues, you must be sure that you are choosing an MSA vendor that has the extensive background and expertise required to successfully challenge your specific issue.

NOTE: Due to recent increased resistance by SSA in providing entitlement information on Social Security and Medicare status, Health Advocates Inc. has revised the Social Security release form and has received approval from the SSA policy office in Baltimore of the release posted on the for this purpose. Use of any other release is done at one's own risk.

Article by June Simpson, President
Health Advocates Inc.
Office: 813.639.1176, Ext. 2222
Fax: 813.639.1395
JSimpson@HealthAdvocatesInc.com

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