OBJECTIVES

1. Provide the reader with a foundation for understanding --

• the Medicare system,
• the Medicare Secondary Payer Act,
• pertinent part of the Medicare Modernization Act of 2003 (MMA)1, and
• the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA)2

2. Approach resolution of claims in a manner that meets the goals of settlement while complying with the significant expectations of the Medicare Secondary Payer Act.

3. Integrate the workers’ compensation and liability claims environment into the Medicare Set-Aside Process.

TABLE OF CONTENTS

I. Introduction
A. History of Medicare
B. The Financing of Medicare
C. System Overview

II. The Medicare Secondary Payer Act
A. History and Applicability to Workers’ Compensation
B. 2003 Medicare Modernization Act and Liability Insurers
C. The MSP after the MMA

III. Knowing the Parties and Their Roles
A. MSA Process
B. Adjusters and Examiners

IV. Overview of Workers’ Compensation

V. Overview of Settlements in the Liability System

VI. Speaking the Language: The Acronyms and References

VII. The New Treasure Map: Mandatory Insurer Reporting
A. Responsible Reporting Entities
B. Triggers
C. Frequency
D. What It Means

VIII. Conditional Payments
A. Defined
B. The Reach of CMS 31
C. Recovery Process 33
D. Time Limits to Seek Recovery
E. Impact
F. Compromise

IX. Taking Medicare’s Future Interests into Account
A. Workers’ Compensation
B. Liability Insurers
C. Negotiation Process

X. The Medicare Set-Aside
A. Defined
B. The Basic Medicare Set-Aside

XI. Allocation Issues
A. The $0 Set-Aside
B. Part D Issues
C. Non-Medicare Covered Items

XII. Submission Considerations
A. Workers’ Compensation
B. Liability Cases
C. Compromise (Percentage) Allocations

XIII. Approval
A. Workers’ Compensation
B. Liability Cases
C. Due Process Concerns

XIV. Funding Issues
A. Annuities / Structures
B. Seed Money
C. Separation of Funding

XV. Administration
A. Consideration
B. Duties
C. Common Issues that Arise
D. Exhausting the Account
E. Death of the Claimant

Endnotes and References
Appendix: CMS Memoranda (7/23/01 thru current - 6/8/10)

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