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  1. #1
    Join Date
    Feb 2010
    Posts
    1

    Default Medicare Set Aside Rules

    I have a friend who recently settled a personal injury lawsuit and has been told that she may have to deal with Medicare set aside rules even though she is not signed up for Medicare, probably never will, and has not received any benefits from Medicare regarding this injury (or any injury).

    Anybosy know anything about this?

  2. #2
    Join Date
    Oct 2006
    Posts
    9,108

    Default Re: Medicare Set Aside Rules

    "An individual has a "reasonable expectation" of Medicare enrollment if any of the following situations apply:

    (a) The individual has applied for Social Security Disability Benefits;

    (b) The individual has been denied Social Security Disability Benefits but anticipates appealing that decision;

    (c) The individual is in the process of appealing and/or re-filing for Social Security Disability Benefits;

    (d) The individual is 62 years and 6 months old (i.e., may be eligible for Medicare based upon his/her age within 30 months); or

    (e) The individual has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.

    To the extent a WC settlement meets both of the criteria (i.e., the settlement is greater than $250,000 AND the claimant is reasonably expected to become a Medicare beneficiary within 30 months of the settlement date), then a CMS-approved Medicare set-aside arrangement is appropriate"


    http://www.cms.hhs.gov/WorkersCompAgencyServices/

  3. #3
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,011

    Default Re: Medicare Set Aside Rules

    PI is much different than WC, and you haven't provided enough info to tell what her/his situation may be. MSA's are unique to the person/applicant and closure of the claim.

    If the PI claim is 3rd party in a comp claim, a MSA would not necessarily be included in that settlement.

    WCMSA's are only necessary where the IW is Medicare eligible as SH has outlined above. The medical in a comp claim doesn't close with out lump sum payment in most cases. The medical in a PI case always closes... where by stipulation agreement, or award by jury. Big difference.

  4. #4
    Join Date
    May 2011
    Posts
    1

    Default Re: Medicare Set Aside Rules

    Thanks BvIA for the reply, it was really helpful.

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