The Future of Medicare Set-Asides – NAMSAP Highlights

Care Bridge International is a proud member of NAMSAP

Leta Sharkey MS, NCC, CDMS, CRP, CLCP, MSCC Vice President, Care Bridge International

What was on everyone’s mind at NAMSAP was HR 2649 and S 1514, Medicare Secondary Payer and Workers’ Compensation Settlement Agreements Act of 2015 which reportedly will be approved by December 7, 2016, according to Doug Holmes, JD of the UWC-Strategic Services on Unemployment and Workers’ Compensation.  The key provisions of this Act are as follows:

  1. Medicare is the secondary payer if the total settlement amount of the claim is $25,000 or less.

  2. Excluded claims include those in which:

  • No future medical is indicated

  • The claimant is not eligible for Medicare benefits as of the effective date of the settlement agreement and is not likely to become eligible within 30 months after the effective date of the agreement

  • No future medical care is indicated, the medical condition is resolved

  1. The Act permits direct payment to the Medicare trust fund, eliminating the need for post settlement self-administration or professional administration of the Medicare Set Aside (MSA).

  2. For MSAs submitted to CMS for review and approval, a 60-day turnaround time including an explanation of deficiencies, will be the performance standard for CMS.

  3. CMS cannot require an employer or insurer to pay more under the WC law than the employer or insurer would normally pay. State WC laws are considered /applied in the “Qualified MSA”.

  4. The use of a “Qualified MSA” is optional; to exercise this option affirms that the payer has resolved outstanding conditional payments and the “Qualified MSA” takes into account the illness/injury; age and life expectancy; reasonableness and necessity of future medical care and expenses related to the illness/injury; duration and limitation on benefits paid under the WC law or plan involved and based upon the fee schedule used by the WC carrier/plan; and regulations and case law relevant to the State WC law or plan.

With the hopeful passage of HR 2649/S 1514 this will allow the WC industry to settle cases using the Qualified MSA which limits their exposure within their limits of liability by recognizing the application of state rules/regulations, fee schedules and medical care for which the WC plan would normally pay.  Further, this bill confirms that a CMS submission is voluntary and that with the qualified MSA, CMS will deem this option as “final and conclusive to any and all matters” related to the WC settlement, provided the carrier has satisfied their obligations in full to any/all outstanding conditional payments.  The Act will provide relief from delays in settling WC claims, protect a claimant’s Medicare benefits, while generating cost savings to both the primary payer and to CMS.

Care Bridge International is the first and only company to offer a true, valid, reliable ‘Qualified MSA’ that meets all the standards of the proposed bill.  Our Qualified MSA is analytic-powered, based upon the predictive modeling of over 175 million medical claim transactions and thousands of Medicare Set Asides, reviewed and approved by CMS.  Our simple streamlined technology based MSP compliance program offers the future of compliance at a fraction of the cost.

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