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Disability Care Managment Professionals

SERVICES

• Medical Set-Aside Program

DCMP has registered nurses on staff that have completed a training program in the Medicare Set-Aside requirements.
Our work product includes the following:

  • Cover letter to Centers for Medicare and Medicaid Services (CMS)
  • Obtain medical release from claimant as required by CMS
  • Contact with Coordination of Benefits Contractor
  • Determination of any potential conditional payments
  • Identification of pre-existing conditions
  • Projected costs for Medicare covered services based on WC fee schedule
  • Projected costs for Non-Medicare covered services based on WC fee schedule
  • Projected future treatment plan based on contact with current treating providers
  • Costs for Medicare covered drugs under Medicare Part D based on average wholesale price
  • Review of medical records for at least most recent 2 year period
  • Review of payment history for at least most recent 2 year period
  • Settlement agreement or proposed court order signed by parties

A CMS approved MSA is required under the following circumstances:

  • Claimant is a Medicare beneficiary at the time of settlement and the settlement is $10,000 or greater  (Class 1)
  • Total settlement is $250,000 or greater and claimant has a “reasonable expectation” of enrolling in Medicare within 30 months of the settlement date (Class 2) Note: Computation of settlement amount includes but isn’t limited to fees, wages, all future medical, payout totals for all annuities and repayment of any Medicare conditional payments
Note:  While CMS has said they will no longer review cases where the total settlement is less than $10,000,  an MSA may still be needed if the claimant is on SSD or Medicare, has applied for SSD and been refused but anticipates re-applying, is within 30 months of being Medicare eligible and/or if the $10,000 threshold is met if the settlement amount included a previously settled portion of the WC claim, repayment of any conditional payments or payout totals for any annuities.

 

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