Medicare Set Aside Allocations


	Electronic mail:	marilyn@bluebeaconmedical.com
	Telephone:	(916) 257-9775
	FAX:	(916) 543-5913
	Postal address:	P.O. Box 1107 Roseville, CA 95678

Specific services provided:

Determination of Social Security eligibility
Verification of Medicare Lien status
Research and formulate Medicare Allocation amount
Submission to Centers for Medicare and Medicaid Services for approval
Coordinate with Attorneys, Settlement Brokers and Centers for Medicare and Medicaid Services (CMS) throughout approval of the allocation.
Communication and updates regarding new laws and processes

What is a Medicare Set Aside Allocation?

A Medicare Set Aside Allocation is a projection of future medical costs that are anticipated to be covered by Medicare over a person’s lifetime that are associated with a Workman’s Compensation claim. The amount of the allocation is set aside in order to cover costs that Medicare would have to pay if there was not another funding source. These costs are set aside to protect Medicare’s interests.

History of Medicare Set Asides:

Legislation was introduced in early 1980 in an effort to conserve money and to protect Medicare and Social Security funds. The legislation was not enforced until 1995, halting the practice of shifting the burden of future care costs to Medicare and making the initial insurance source put aside money and seek approval from the regional CMS office regarding the allotment prior to the final settlement.

There are two situations described by CMS in which a settlement will require a MSA:

If the settlement involves an injured party that is already a Medicare recipient, regardless of the dollar amount of the settlement. This would include the older injured worker who is Medicare eligible based on age, as well as the younger Medicare recipient based on SSD eligibility.
If the person meets this “two-pronged” test:

The injured party must have reasonable expectation of becoming a Medicare recipient within the next 30 months ie: they have applied for SSD or they have been denied and are appealing the decision or they are 62 ½ years old or they have end stage renal disease, but are not yet on Medicare
AND - the TOTAL settlement value (indemnity, medical and attorney fees) is greater than $250,000.

The MSA requires evaluation of the medical records with additional input from the patient, medical providers, insurance carriers and attorneys. It is necessary to evaluate the most accurate and current information regarding care and costs of that care so that an appropriate allocation can be formulated and presented to CMS for approval. The consultant continues to assist with securing approval by keeping in constant communication with CMS to answer questions and provide additional documentation as needed.