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GENEX Services, Inc.

GENEX Services, Inc. Medicare Set-Aside. Medicare Set-Aside.

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GENEX Services, Inc.

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  1. GENEX Services, Inc. Medicare Set-Aside

  2. Medicare Set-Aside Carriers are under increasing pressure to protect Medicare’s interests when settling claims. Medicare Set Aside Programs assists Worker’s Compensation Carriers in meeting this obligation by determining appropriate set-aside amounts and gaining Medicare approval.

  3. History • Medicare was enacted in 1965 to provide national health insurance to the aged, disabled, and those with end stage renal disease. • Medicare Secondary Payer (MSP) statute was enacted in 1980 to curb the rising cost of Medicare.

  4. Statutory Authority • Requires that Medicare provide services only as a “secondary” payer. • 42 CFR 411.32 • Medicare payment can not be made for any item or service to the extent that payment has been made or can be reasonably expected to be made. • 42 USC 1395y(b)(2)

  5. When Must Medicare’s Interests Be Protected? In every case that is settled for future medicals.

  6. Why Protect Medicare’s Interests? • Failure to protect Medicare’s interests can result in legal action against the beneficiary, attorney, insurance carrier, self-insured employer/insurer. • If legal action is necessary, Medicare may recover double damages.

  7. Why Protect Medicare’s Interests? • If a settlement appears to represent an attempt to shift the responsibility for payment of medical expenses for the treatment of a work-related condition to Medicare, the settlement will not be recognized. 42 CFR 411.46

  8. How Do You Protect Medicare’s Interests • Not clearly defined • An appropriate amount of settlement money must be “set-aside” for payment of future medical costs that would otherwise be Medicare compensable. • After the set-aside has been spent on medical costs, Medicare will pay for work related injury costs.

  9. Threshold • Medicare must approve a set-aside in any case in which: • the claimant is entitled to Medicare and the settlement amount is over $10,000; OR • the settlement amount is over $250,000 and there is a reasonable expectation that the claimant will be entitled to Medicare within 30 months of the settlement date.

  10. MSA Proposal • To gain Medicare approval, parties need to submit a Medicare Set-Aside Proposal to CMS. • The proposal identifies: • the amount of money to be set-aside for future Medicare covered medical costs. • The allocation is based on an analysis of the condition, current treatment, projected future treatment, and life expectancy. • The allocation must now include prescription drug costs.

  11. MSA Proposal • The proposal also specifies: • The method for funding the account • lump sum or an annuity • The method for administering the account. • professionally or self-administered

  12. Medicare Approval • Once the proposal is approved, settlement can occur with confidence that Medicare’s interests have been protected. • Approval ensures that Medicare will pay for expenses incurred after the set-aside amount has been exhausted.

  13. Conditional Payments • In some circumstances, Medicare will make payment on claims that should have been paid by the carrier. • These are called conditional payments.

  14. Conditional Payments • Medicare’s approval of the proposal eliminates liability for payment of future medical expenses but does not cover conditional payments made prior to settlement. • Conditional payments should be considered in settlement negotiations.

  15. Types of Services • Social Security and Medicare status determination • Includes: • Status determination • Recommendation regarding need for Medicare Set-Aside Proposal submission and approval

  16. Types of Services • Medicare Set-Aside Cost Projection • Includes: • Status determination • Medicare Set-Aside recommendation • Includes cost projection of Medicare covered costs • Recommendation for frequency and amount of periodic payments when structured settlement is being utilized • Determination of life expectancy or rated age • Medicare conditional payment identification

  17. Types of Services Types of Services • Complete Cost Projection with Medicare Set-Aside Cost Projection Includes: • All aspects of the Medicare Set-Aside Cost Projection plus cost projection of non Medicare covered costs over the life expectancy.

  18. Types of Services • Medicare Set-Aside Submission Includes: • Completion of Medicare Proposal • Submission of Proposal to Medicare • Follow-up with Medicare and negotiation until approval is obtained

  19. Additional Tools • Life Care Plan • Social Security Representation

  20. Important Timeframes • Eligibility verification • Cost projection All projections are provided to the carrier for initial approval • Submission to CMS • Submission Approval

  21. Other Provider Questions • Will they offer assistance obtaining patient signatures and copying / scanning medical records? • Who is responsible for the completion of the cost projection? • Are attorneys on staff who are involved in the allocation and submission? • Approval Rating / Resubmission Charges

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