(Test 1) If the claimant is currently a Medicare beneficiary AND the settlement exceeds $25,000;

(Test 2) The claimant has a reasonable expectation of becoming entitled to Medicare within 30 months AND the total settlement exceeds $250,000.

How does CMS evaluate the sufficiency of a Medicare Set-Aside Arrangement?

Medicare considers the sufficiency of an arrangement on a case-by-case basis. Some factors they consider include: basis for entitlement to Medicare benefits, nature and extent of the injury, age and workers' compensation classification of the beneficiary, prior medical expenses paid by the insurance carrier, and the total amount of the settlement. MEDVAL’s staff of nurses and attorneys thoroughly review the medical records, consults with the settling parties and treating physicians, and ultimately makes a recommendation that we believe will adequately protect Medicare's interests.

What documents do I need to provide to MEDVAL for a Medicare Set-Aside allocation prepared?

The documents required by CMS are extensive and require proper planning to ensure the case is reviewed in a timely fashion. The most import document to provide is a release from the claimant allowing MEDVAL to discuss the claim with CMS. Furthermore, you will need to provide two years of recent medical documentation, a medical payment summary for the preceding three years, and the proposed settlement documents. Other documents may be required depending on the claim. A complete list of documentation requirements can be found on our DOCUMENT CENTER page.

As of March 2008, CMS takes anywhere from 45 to 120 days to review and approve a case. It is important to plan ahead and get the process moving forward if it is determined that a Medicare Set-Aside arrangement is needed. MEDVAL's policy is to have all Set-Aside arrangements submitted to CMS within 72 hours after a completed package is received and service is requested by the client.

What happens if I do not get CMS approval on a claim that meets the criteria for a Set-Aside Arrangement?

CMS has a direct priority right of recovery against any entity including a beneficiary, provider, supplier, physician, attorney, state agency, or private insurer that has received any portion of a third party payment directly or indirectly. CMS also has a subrogation right with respect to any such third party payment. In layman's terms, if you make or receive any payments and fail to protect Medicare's interest, you can be held liable by Medicare.

Additionally, if you fail to get CMS approval and Medicare deems the settlement an intentional attempt to shift the burden of treatment to Medicare, Medicare may apportion the entire settlement to future Medicare expenses and refuse to pay any Medicare covered medical expense until the entirety of the settlement is exhausted on the treatment of the injury.

A professionally administered MSA is recommended when a beneficiary is unable or unwilling to comply with the many requirements set forth by Medicare for managing the post-settlement Set-Aside arrangement. A professional custodian, like MEDVAL, ensures proper investment, makes payment to medical providers, reduces bills to the appropriate state fee schedule if necessary, and submits the required accounting to CMS on an annual basis.

MEDVAL strives to be the reasonable cost, high quality provider. Because we handle all aspects of a Medicare Set-Aside arrangement from initial negotiation to final approval, we can charge less than our individual competitors who often outsource services. Our complete fee schedule can be found on our DOCUMENT CENTER page.

If you are a new client and are unfamiliar with the Medicare Set-Aside process, you should call our office and speak to someone about your specific situation. Once you become familiar with the process and our services, you can make a referral by fax, email or via our dedicated web portal. Our contact information can be found on our CONTACT US page.