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Medicare Set-Aside

A Medicare Set-Aside is a financial arrangement that guarantees funds are "set aside" and made available for future medical expenses for worker's compensation and liability cases. The amount of the set aside is determined on a case-by-case basis. When appropriate, the set aside should be submitted and reviewed by CMS.

The current guideline is that a carrier/employer or claimant must submit a settlement for CMS approval when 1) the claimant is currently a Medicare beneficiary and the total of the settlement is greater than $25,000; or the claimant has a "reasonable expectation" of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement is expected to be greater than $250,000.

Standard MSA

  • Single injury date
  • Single body part (Ex. Lumbar strain, cervical strain, Thoracic strain, Knee injury, etc.)
  • Review of Medicals
  • Report preparation
  • Breakdown of Medicare and Non-Medicare cost
  • Sending appropriate forms to claimant attorney, defense attorney and CMS

Complex MSA

  • Multiple injury dates
  • Multiple body parts
  • Multiple Surgeries
  • Review of Medicals
  • Report preparation
  • Breakdown of Medicare and Non-Medicare cost
  • Sending appropriate forms to claimant attorney, defense attorney and CMS

Submissions

  • Submissions will be billed as an additional charge to Standard and Complex MSA’s
  • SSA-3288 form, Medicare Release of information form and general release forms will all be sent to CMS to verify Medicare eligibility and Medicare lien status.
  • RN will follow up closely with the lead contractor on the submission status until the file is approved by CMS

Drug Utilization Review

  • Pharmacist will review medical records and payment history to identify appropriate and cost effective drug utilization.
  • Provide recommendations to reduce projected costs for future prescription drug utilization.
  • A valuable tool in reducing the future prescription cost in an MSA.

Forms:

To request Medicare Set-Aside service, fill out the form below.

Note: Required fields are marked with an asterisk ( * ).

Service Request Date 

Referral Form Medical records for past 3 years
FROI Signed release/consent forms
Medical Claims Payout History for past 2 years Pharmacy and DME history for past 3 years

Type of Referral (Please check appropriate box)

WORKERS COMP
LIABILITY

Medicare Set-Aside
CMS Submission
Life Care Plan
Full Medical Cost Projection
Brief Medical Cost Projection

SS/Medicare Verification

Referral Source

Adjuster Name: *
Phone: *
E-mail: *
Carrier/TPA: *
Address: *
City: *
State: *
ZIP: *
Preferred Annuity Company
for Rated Age:
Pharmacy Vendor:

Claimant Information
Name: *
Phone: *
Address: *
City: *
State: *
ZIP: *
Claim Number: *
State of Jurisdiction: *
Diagnosis: *
Date of Birth: *
Date of Injury: *

Employer Information
Employer: *
Address: *
Phone: *

Attorney Information
Plaintiff Attorney:
Phone:
Fax:
Address:
City:
State:
ZIP:
Email:
   
Defense Attorney:
Phone:
Fax:
Address:
City:
State:
ZIP:
Email:
   
Notes/Special
Handling Instructions:
 



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