Legal Nurse Consulting
Case Management
Life Care Planning
Medicare Set A-Side
Coordination of Care
Healthcare Auditing
Medical Consulting
Business Consulting
Educational Services
Consulting Services
Medicare Set A-Side

The preparation of a Medicare Set A-Side is a complex, detailed-oriented and challenging process. Our experience leads to decreased settlement costs, lowest defensible Set A-Side amounts, and quick turn around times.

“Analyzers R Us’ has experience with Medicare benefits, Red Books average wholesale costs, case management and legal nurse consulting. In addition to claims analysis and medical records analysis which allows Analzyers R Us to provide a complete picture for our clients.”

Medicare Set A-Side:x

All parties in a workers' compensation (WC) case or third-party liabilities (TPL) case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare's interests when resolving WC and TPL cases that include future medical expenses.

The recommended method to protect Medicare's interests is a Workers' Compensation Medicare Set A-Side Arrangement (WCMSA), which allocates a portion of the WC settlement for future medical expenses. The same method is highly recommended for TPL cases, but Medicare has not issued a ruling as of today, other than to state that Medicare’s interests must be reasonably considered and funds need to be Set A-Side for future medical expenses that would be covered by Medicare related to the medical liability case.

The amount of the Set A-Side is determined on a case-by-case basis and should be reviewed by the Centers for Medicare/Medicaid Services (CMS), when appropriate. Once the CMS-determined Set A-Side amount is exhausted and accurately accounted for to CMS, Medicare will agree to pay for future Medicare-covered expenses related to the WC injury.

What Are MSAs?

Medicare Set A-Side (MSA) Allocations are federally mandated accounts that provide necessary funding to cover future injury/illness related to Medicare-allowable medical expenses for qualified individuals.

Why Are MSAs Required?

The federal government has mandated that MSAs must be funded adequately to cover future allowable medical expenses. The goal of the MSA legislation is to protect Medicare from being thrust into the primary payer role, when it should be the responsibility of another entity. This would properly place Medicare in the role of secondary payer.

How Are MSAs Funded?

MSAs are created via the establishment of a funding account (either lump sum, structured annuity or combination) with a proper funding mechanism and administration oversight.

Who Qualifies For MSAs?

  • A claimant who: is currently a Medicare beneficiary and holds a settlement of $25,000.00 or greater
  • there's is a “reasonable expectation” of Medicare enrollment within 30 months and the total settlement amount is expected to exceed $250,000 (meaning the total uncommuted value of the settlement includes past & future medicals, indemnity (wages), attorney’s fees & costs and any Medicare overpayments. If a structure, count the total of all expected payments- do not use present value.)
  • other situations, i.e. Medicare entitlement with date certain; SSD recipient and settlement is below $250,000; age 64 at time of settlement=MSA is recommended, but no submission.

Reasonable expectation include, but is not limited to claimants who:

  • have applied for social security disability benefits (SSDB)
  • have been denied by SSDB & are re-applying, or anticipate appealing
  • are 62 ½ years of age
  • have End Stage Renal Disease (ERSD)

Should settlement agreement for a qualifying client be reached without the Centers for Medicare/Medicaid Services (CMS) approval of adequate financial protection for Medicare/Medicaid, CMS could order re-examination of the settlement, require a restructuring or re-negotiation and assess fines and penalties. Or Medicare could state that the whole settlement is for future medical expenses and must be exhausted prior to Medicare benefits related to the accident being covered in the future.

© 2013 Analyzers R Us, All Rights Reserved
Scottsdale Web Site Design by Artistik Designs
Home | About Us | Company Profile | Services | Contact