Medicare Set Aside
At Denise W. Wrenn & Associates, our Medical Legal Nurse Consultants are professional, highly-skilled, registered nurses who bring their training forward to provide services with attorneys on medical related cases.
Our professionals provide an accurate projection of the anticipated Medicare and non-Medicare covered services related to your client’s future medical costs through the individual’s life expectancy. This cost may be associated with Workers' Compensation Medicare Set-Aside Arrangement (WCMSA), a Liability Insurance Medicare Set-Aside Arrangement (LMSA), or a No-Fault Insurance Medicare Set-Aside Arrangement (NFMSA).
Cost projections include a detailed description of each allocated service by Medicare, including Part D prescription and Off-Label Drug review while thoroughly determining the amount of money to “set aside” from the settlement proceeds for future medical costs.
What is a Medicare Set Aside (MSA)?
An MSA is a financial arrangement that allocates a portion of a settlement, judgment, award, or other payment to pay for future medical services. When future medical care is claimed, or settlement, judgment, award, or other payment releases (or has the effect of releasing) claims for future medical care; it can reasonably be expected that the monies from the settlement, judgment, award or other payment are available to pay for future medical items and services which are otherwise covered and reimbursable by Medicare.
Medicare is always a secondary payer to liability insurance (including self-insurance), no-fault insurance, and workers’ compensation benefits. The law precludes Medicare payment for services to the extent that payment has been made, or can reasonably be expected to be made promptly, under liability insurance (including self-insurance), no-fault insurance, or Workers’ Compensation (WC). (See Section 1862(b)(2)(A) of the Social Security Act, cited in the U.S. code at 42 U.S.C. § 1395y(b)(2)(A)(i)).
Medicare Allocation Services:
Projections of Medicare allowable injury related expenses, including Part D prescription
Social Security and Medicare status determination
Reporting to COBC to initiate a Medicare conditional payment claim investigation
Determination of rated age life expectancy (additional cost)
Medicare Conditional Payment Claim Investigation
Conditional payment research
Medicare Conditional Payment Claim Negotiation
Recommendations regarding the appropriateness of Medicare's claim
Other MSA Services:
Do you have additional questions about your Medicare Set Aside?
Let us walk you through a few of the commonly asked questions about Medicare Set Aside below.
By Federal law, Medicare is always a “secondary payer” which means if there is any other insurance available – for example from a workers’ compensation or a personal injury suit – Medicare will not pay bills for your injury unless that insurance becomes unavailable. Since you received settlement money from an insurance company to cover your future medical treatments, Medicare wants to make sure that you spend that portion of your settlement money on injury related care, before the taxpayers start paying for your injury through Medicare.
The way Medicare ensures that it does not pay bills for your injury until your settlement funds are spent is through a Medicare Set-aside Allocation (MSA). An MSA is projection of the cost of the future treatment for your injury including doctor’s visits, tests, surgical procedures, and medications. The MSA amount, as set forth in the CMS Determination and settlement documents, must be then be placed into a Medicare Set-aside Account and spent on treatment for your injury.
When an injury settlement is made, the intention is for the money to cover the injured person's medical needs for their lifetime . . . but sometimes the money runs out. If the money does run out, Medicare will step in and help, but only if the MSA Account has been in compliance with every rule and regulation that Medicare has including spending, record keeping and reporting. It is very easy to jeopardize your future Medicare eligibility for your injury.
MSA Accounts require detailed record keeping and reporting to CMS (Centers for Medicare and Medicaid Services), and have many restrictions about how the money in the account can and cannot be spent. Medicare rules dictate that you only pay for medications and procedures that are covered by Medicare and that you only pay the approved price for each bill. They also require that you keep records and receipts, and that you report all expenses to Medicare. If mistakes are made -- the injured person can risk future entitlement to Medicare benefits.