FOR MORE INFORMATION:

MANAGER Karen Miller
TELEPHONE 501.227.5553 or 800.822.2680
FAX      501.227.8362
TO REFER Systemedic MSA Referral Form.pdf
(Click the link above and print the form)

Medicare Set-Aside Services

Medicare Secondary Payer Statute

Primary payers in workers’ compensation and liability are required by the Medicare Secondary Payer (MSP) statute to protect Medicare’s interest in any settlement in which future medical expenses are a component. Payers must determine if a Medicare Set-Aside (MSA) is indicated, and, if so, whether it requires approval by the Centers for Medicare and Medicaid Services (CMS).

Compliance with the statute can be a cumbersome, if not bewildering, process that carries financial and liability risks if not carried out properly. As a long-time trusted resource in workers’ compensation and liability, Systemedic is ready to help you comply with the MSP.

Systemedic and its service partners offer the following services, customized and unbundled, so you may choose only those specific services you need.

MSA Preparation

  • Obtain, organize, and review records of prior medical care and expenses
  • Determine CDC life expectancy or rated age, as appropriate
  • Prepare a detailed analysis of probable future Medicare allowable injury related medical needs and projected cost over the life expectancy of the injured worker
  • Forward comprehensive MSA report within 10 business days* to aid in a settlement decision

    (* 10 days begin after all needed records are received; expedited service is available)

  • Secure necessary consent forms, if requested
  • Initiate a Medicare conditional payment investigation, if requested

Funding Options

  • Provide funding options with quotes (free service)
  • Implement a selected funding option upon request

Submission to the CMS

  • Collect required settlement documents
  • Prepare cover letter and form required by CMS
  • Digitize all documents and medical records, indexed according to CMS requirements
  • Submit completed package to the appropriate CMS Coordination of Benefits Contractor (COBC)

Post-settlement MSA Fund Administration
(Post-settlement administration is provided by Systemedic’s service partner, DataPath MSA Services.)

The DataPath program uses a web-based, state-of-the-art software administration platform that is unparalleled in the care account services industry. The features of this proprietary system include:

myMSA Resource Card

  • Patented Claim Payment Card
  • Card Transaction/Claim Payment data stored in administration system for CMS required reporting

Claims Vault (patented electronic shoebox for retention of claims/receipts)

Compliance Services — CMS Compliant Accounting and Reports

  • Annual CMS reports
  • Final report—exhaustion of funds
  • Interim reports in audit situations
  • Interest accounting for tax purposes

The DataPath program offers three models for the administration of an MSA Account:

Account Management Models

  • Independent Management—total injured worker-directed account management
  • Joint Management—injured worker-directed management with DataPath support
  • Specialist Management—DataPath-directed management with injured worker interaction

Account Fees

  • Case-rated fee structure
  • Cost effective and affordable for the Payer
  • Engages management model for the life of the account

Also see our Life Care Plan Service.

Does your settlement require an MSA? What about CMS approval?

Injured worker entitled to Medicare now

  • Total settlement is under $25,000:

    MSA is required; submission to CMS is NOT required

  • Total settlement is over $25,000:

    MSA is required; submission to CMS is required

Injured worker entitled within 30 months of settlement date

  • Total settlement is under $250,000:

    MSA is required; submission to CMS is NOT required

  • Total settlement is over $250,000:

    MSA is required; submission to CMS is required

Injured worker not entitled within 30 months of settlement date

  • Total settlement is under $250,000:

    MSA is NOT required; submission to CMS is NOT required

  • Total settlement is over $250,000:

    MSA is NOT required; submission to CMS is NOT required

Note that these are CMS workload review thresholds and do not constitute a “safe harbor.” The parties to a workers’ compensation or liability settlement are still required to consider Medicare’s interests to ensure that Medicare is secondary to either a workers’ compensation or liability payer.

Computing Total Settlement Amount

The computation of the total settlement amount includes, but is not limited to, wages, attorney fees, all future medical expenses (including prescription drugs), and any conditional payment amounts.

If an annuity is used to fund the MSA, the total payout of the annuity over the life of the settlement must be used, not the initial cost or present value of the annuity.

Why should you consider professional post-settlement administration of the MSA fund?

One does not escape the MSA maze once the settlement and MSA arrangement are finalized. The post-settlement challenge of Medicare compliant administration remains for the life of the account.

Failure in compliant administration can negatively impact the well-being of the injured worker/beneficiary and impose liability on any party responsible for the formation of the arrangement. CMS claims “a right of action to recover its payments from any entity, including a beneficiary, provider, supplier, physician, attorney, State agency, or private insurer.”