How to Take Medicare’s Interests Into Account:
Administering the Medicare Set Aside

MSA allocations may be administered by the claimant.
However, stringent guidelines must be followed because
beneficiaries are held to the same standards to which a
professional administrator is held with regard to what may
and may not be paid from the MSA account. In addition, the
same reporting requirements must be met. MSA funds can
only be used to pay for the claimant’s future injury-related
medical expenses that would otherwise be covered by Medicare. This will require that the individual handling the MSA administration have the expertise to be fluent with Medicare allowable medical treatment, specific medical fee schedules, and medical claims administration. In other words, if self-administered, the claimant should have sufficient experience and knowledge in these areas to be able to make reasonable determinations about whether individual medical expense claims are injury related, which expense claims would be covered under Medicare, and the rates at which such bills should be paid.

Our Focus: Professional Administration of Medicare Set Aside Accounts

While MSA allocations may be self-administered, the better practice is to use a professional administrator. Indeed, this is clearly the more advisable procedure in situations where the claimant has a guardian or is otherwise unable to manage his or her own funds; the amount of the MSA is significant; or, the medical care is expected to be extensive. With all such accounts administered by the Center, medical providers may send bills for their services directly to us. Our administration experts pay the medical bills in accordance with either the usual or customary fee or the applicable state fee schedule, depending upon which fee schedule the settlement agreement indicates or upon which the allocation was based. We are limited, however, in what may be paid from the MSA account with regard to medical expenses. We can only pay for treatment that Medicare would cover. In addition, the funds must only be used to pay for medical expenses connected with the claimed accident or resulting injury.

Our Administration Experts: Accounting for All Deposits and Expenditures

At least on an annual basis, our administration experts comply with CMS reporting requirements by sending reports to the appropriate Medicare regional office. These reports include an accounting of all expenditures from and deposits made into the fund for that period of time. When the fund is exhausted, our administration experts will also forward a final report to the appropriate Medicare regional office detailing all expenses paid from the fund and all deposits for the life of the fund. Upon approval of the report, our duties as professional administrator end. Should the claimant die before the MSA account is exhausted, the money will revert to his/her estate, to the employer/carrier, per contract, or per state law. In such a case, our administration experts will ensure that after all CMS required payments have been made from the account, the appropriate transfers are made before being released from any further obligations in connection with the MSA.

Medicare’s Payments While Claim is Open
Medicare insists, without question or doubt, that any payments it makes for medical services in an open claim are to be reimbursed as part of the settlement of the claim. There is no controversy about this issue. If the parties are settling a claim, they must ensure any Medicare payments for medical services related to the injury are reimbursed as part of the settlement. If you fail to do this, Medicare will pursue reimbursement from any and all sources, including the attorneys. 7-23-01 CMS Memorandum.
When a Reasonable Expectation of Medicare Eligibility Exists
A reasonable expectation of receiving Medicare within 30 months of settlement exists when the injured party: 1) has applied for Social Security Disability (SSD); 2) has been denied SSD but has, or plans to, re-file or appeal; 3) is older than 62 years and 6 months and will therefore turn age 65 within 30 months; or 4) has End Stage Renal Disease.