When to do an MSA and CMS Submission

  • By admin
  • 28 June, 2013
  • Comments Off on When to do an MSA and CMS Submission

We often get the question about CMS submissions and MSP qualifications so this blog entry will attempt to clarify that information.

When to do an MSA?   It is important to consider doing a Medicare Set-Aside (MSA):

  • When an injured worker has been off of work for over two years on Workers’ Compensation Temporary Total Disability
  • For open ended disability cases
  • When the injured worker is 65 years of age or older (as long as they have paid Federal Insurance Contributions Act (FICA) during the years they worked)
  • When the injured party has potential eligibility to be on Medicare within 30 monhts of the date of settlement (i.e., has applied for or is collecting SSDI)
  • When a settlement is being formulated that involves irrevocable closure of future medical benefits
  • When any portion of the settlement may represent future medical treatment where the injured party may qualify for SSDI or Medicare
  • When the injured party is Medicare entitled at the time of settlement (either via age, by virtue of being on SSDI for 24 months, or because of a catastrophic injury)
  • When the injured party has potential Medicare entitlement within 30 months of the date of settlement.  This means they have filed for SSDI, or are collecting SSDI for less than 24 months, or are 62.5 years of age.
  • By securing an SSA-3288 release for eligibility verification
  • When SSDI application effectively makes a claimant Medicare eligible within 30 months of settlement according to CMS
  • When the injured party is Medicare eligible at the time of the settlement

MSA Submission to CMS  It is important to only submit to CMS what falls into their guidelines:

  • When the injured party is entitled to Medicare at the time of settlement and
    • The settlement is under $25,000 – it is highly recommended to do an MSA to prove you have considered MSP future medical costs, but no CMS approval is required
    • The settlement is over $25,000 – it is highly recommended to do an MSA to prove you have considered MSP future medical costs and encouraged to submit to CMS for approval of the amount to set-aside
  • When the injured party is not yet entitled to Medicare at the time of settlement, but has potential eligibility within 30 months of settlement (have filed for SSDI, or are collecting SSDI for less than 24 months, or are 62.5 years of age.)
    • The settlement is under $250,000 and are not eligible for Medicare within 30 months of settlement, then no MSA is required and no submission to CMS is required for approval.
    • The settlement is over $250,000 and they are not eligible for Medicare within 20 months of settlement, then no MSA is required and no submission to CMS for approval is required.
    • The settlement is over $250,000 and will be eligible for Medicare within 30 months of settlement – it is highly recommended to do an MSA to prove you have considered MSP future medical costs and encouraged to submit to CMS for approval of the amount to set-aside
    • The settlement is over $250,000 and are eligible for Medicare at time of settlement then it is highly recommended to do an MSA to prove you have considered MSP future medical costs and encouraged to submit to CMS for approval of the amount to set-aside
  • The submission process typically takes two to four months
  • The requirements and process differs between the ten regional CMS offices
  • There are no appeal provisions if the MSA amount is rejected currently, but under SMART ACT (HR 1845) under certain conditions (see Quick View of  Bill HR 1845 Changes for further detail).

 

 

 

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