Health Under Medicare

Medicare Set-aside ProposalSubject on Medicare due to mental disability - had a workers comp case settlement - for which a set aside for health care only was arranged.

• • All parties in a Workers’ Compensation (WC) case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare’s interests when resolving WC cases that include future medical expenses. The recommended method to protect Medicare’s interests is a Workers’ Compensation Medicare Set-aside Arrangement (WCMSA), which allocates a portion of the WC settlement for future medical expenses. The amount of the set aside is determined on a case-by-case basis and should be reviewed by CMS, when appropriate. Once the CMS determined set aside amount is exhausted and accurately accounted for to CMS, Medicare will agree to pay primary for future Medicare covered expenses related to the WC injury.
• Medicare Set-aside Proposal

A state cannot take away an MA (Medical Advantage) organization;s right under federal law and the Medicare Secondary Payer (MSP) regulations to bill, or to authorize providers and suppliers to bill, for services for which Medicare is not the primary payer. The MA organization will exercise the same rights to recover from a primary plan, entity, or individual that the Secretary exercises under the MSP regulations. [42 C.F.R. Sect. 422.108(f)]

2007 CCH Medicare Explained - Paragraph 402

The MEDICARE LIENS
Checklist for Medicare’s Interests
in Workers Compensation Settlement

Medicare Liens.pdf (application/pdf Object)

The information on this article may be dated - subsequent legislation or case law may need to be checked out

 The MSP Statute:
Impact Of The Medicare Prescription Drug,
Improvement & Modernization Act Of 2003

Lewis-on-MSP.pdf application/pdf Object

Medicare and No-fault or Liability Insurance (continued)
How does Medicare get its money back for the conditional
payment?
If Medicare makes a conditional payment, and you or your attorney
haven’t reported your no-fault or liability claim to Medicare, then
you should call 1-800-MEDICARE (1-800-633-4227) and they will
connect you to the Medicare Coordination of Benefits Contractor
(COBC). If your attorney contacts Medicare, your attorney should
call the COBC at 1-800-999-1118. The COBC will assign a
Medicare contractor to work on your case. This contractor will use
the information that you gave to the COBC to start gathering
information about any conditional payments Medicare made which
relate to your pending settlement, judgment, or award. Once a
settlement, judgment, or award is final, you or your attorney should
call the Medicare contractor assigned to your case. This contractor
will get the final repayment amount (if any) on your case, and issue
a demand letter requesting repayment.
Who pays if the no-fault or liability insurance doesn’t pay, or
denies my medical bill?
In this case, Medicare will pay first. However, Medicare will only
pay for Medicare-covered services. You will be responsible for your
share of the bill (for example, coinsurance, copayment, or
deductible), and bills for services that Medicare doesn’t cover.
Who should I call if I have questions?
If you have questions about a no-fault or liability insurance claim,
call the insurance company. If you have questions about who pays
first call 1-800-MEDICARE (1-800-633-4227) and they will
connect you to the Medicare Coordination

from “Your Guide to Who Pays First” by CMS page 15

Medicare and No-fault or Liability Insurance

If I expect to get money from no-fault or liability insurance,
and I also have Medicare, which one should pay first?
No-fault or liability insurance should be the primary payer. If doctors or
other providers decide that the services you received can be paid for by a
no-fault or liability insurance company, they must try to get payments
from the insurance company before billing Medicare. However, this
may take a long time. If the insurance company doesn’t pay the claim
within 120 days, your doctor or other provider may bill Medicare.
Medicare may make a conditional payment to pay the bill.

What is a conditional payment?

A conditional payment is a payment that Medicare makes for services
for which another payer is responsible. This conditional payment is
made so you won’t have to use your own money to pay the bill. The
payment is “conditional” because it must be repaid to Medicare when a
settlement, judgment, or award is reached.
Note: If Medicare makes a conditional payment, and later you get a
settlement from an insurance company, Medicare will recover the
conditional payment from your settlement, judgment, or award. You are
responsible for making sure that Medicare gets repaid for the
conditional payment.

(5) [9:350] Discipline for failure to honor lien: Generally, an attorney’s failure to honor a valid lien despite knowledge thereof is cause for discipline. [Matter of Riley (Rev.Dept. 1994) 3 Cal. State Bar Ct.Rptr. 91, 110–112—includes liens for Medi–Cal, MediCare and county-furnished medical benefits; but see discussion at ¶ 9:319]

Similarly, failure to promptly pay liens when funds are withheld from settlement to satisfy such liens can result in discipline. [Matter of Mapps (Rev.Dept. 1990) 1 Cal. State Bar Ct.Rptr. 1, 6–7]

a. Types of liens(1) [9:313] Statutory liens: Third party liens on client funds may arise by statute. For example:

• Lab C. Sec. 3856 (workers’ compensation lien).

• Welf. & Inst.C. §§ 14124.72–14124.791(Medi–Cal lien).

• Gov.C. § 13966.01 We (lien for state restitution fund payments to crime victims).

• Gov.C. § 23004.1 (lien for county medical benefits).

• Civ.C. §§ 3045.1–3045.6 (hospital lien for emergency medical care/services).

(a) [9:314] Statutory notice requirements: Some of these statutes require the lawyer to provide notice to the lienholder regarding settlement and/or impose other duties. [See Welf. & Inst.C. § 14124.76 (requiring notice to Director of Health Services before judgment, award or settlement may be satisfied); see also Matter of Respondent P (Rev.Dept. 1993) 2 Cal. State Bar Ct.Rptr. 622, 630—attorney had fiduciary duty to notify Director of beneficiary's impending settlement]