GENEX Services, Inc. Presentation of

GENEX Services, Inc. Presentation of
Medicare Set Aside 2008 Update 1/4/2008 © 2007 GENEX Services, Inc. All rights reserved

Presentation Overview
Review the History of Medicare Set Asides Who is involved in Medicare Set Asides New Legislation What the new legislation means to you GENEX Medicare Set Asides Services 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

© 2008 GENEX Services, Inc. All rights reserved
History Medicare was enacted in 1965 to provide national health insurance to the aged, disabled, and those with end stage renal disease. Medicare Secondary Payer (MSP) statute was enacted in 1980 to curb the rising cost of Medicare. 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Medicare Set Aside (MSA)
Definition: Money set aside to cover future medical treatment at the time of settlement of liability, no fault, self insured, auto, and workers compensation claims. Purpose: To protect Medicare’s interest as a secondary payer. 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Medicare Set-Aside Carriers must protect Medicare’s interests when settling claims. GENEX’s MSA Program assists carriers in meeting their obligation by determining appropriate set-aside amounts and gaining Medicare approval. Liability Insurance (including self-insurance). No Fault Insurance Worker’s Compensation 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Medicare Set Aside 2008 Update
Legislation & Impact Medicare Set Aside 2008 Update 1/4/2008 © 2007 GENEX Services, Inc. All rights reserved

Statutory Authority Requires that Medicare provide services only as a “secondary” payer. Liability Insurance, Self-Insured, No Fault Insurance, Auto, and Workers’ Compensation are primary. Medicare payment can not be made for any item or service to the extent that payment has been made or can be reasonably expected to be made by a primary insurance. 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

New Legislation Last Action Dec 29, 2007 Became Public Law No: (Gov) Signed by President Dec 29, 2007 Passed House Dec 19, 2007 Introduced & Passed Senate Dec 18, 2007 Legislation (110th Congress) S. 2499: Medicare, Medicaid, and SCHIP Extension Act of 2007 A bill to amend titles XVIII, XIX, and XXI of the Social Security Act to extend provisions under the Medicare, Medicaid, and SCHIP programs, and for other purposes. 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Who is included in the Legislation?
(F) APPLICABLE PLAN - In this paragraph, the term `applicable plan' means the following laws, plans, or other arrangements, including the fiduciary or administrator for such law, plan, or arrangement: Liability insurance (including self-insurance). No fault insurance. Workers' compensation laws or plans. (S.2499) 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Implementation (c) Implementation- For purposes of implementing paragraphs (7) and (8) of section 1862(b) of the Social Security Act, as added by subsection (a), to ensure appropriate payments under title XVIII of such Act, the Secretary of Health and Human Services shall provide for the transfer, from the Federal Hospital Insurance Trust Fund established under section 1817 of the Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of such Act (42 U.S.C. 1395t), in such proportions as the Secretary determines appropriate, of $35,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for the period of fiscal years 2008, 2009, and (S.2499) 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

SEC. 111. Medicare Secondary Payor
(B) ENFORCEMENT- (i) IN GENERAL- An entity, a plan administrator, or a fiduciary described in subparagraph (A) that fails to comply with the requirements under such subparagraph shall be subject to a civil money penalty of $1,000 for each day of noncompliance for each individual for which the information under such subparagraph should have been submitted. The provisions of subsections (e) and (k) of section 1128A shall apply to a civil money penalty under the previous sentence in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a). A civil money penalty under this clause shall be in addition to any other penalties prescribed by law and in addition to any Medicare secondary payer claim under this title with respect to an individual. (Gov) 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Impact of Legislation Any claim that is settled and is eligible or may be eligible in 30 months for Medicare benefits must protect Medicare’s interest as a “secondary” payer. CMS (Centers for Medicare & Medicaid Services) reviews the allocation on a case-by-case basis. Once CMS has reviewed and approved of the allocation, the medical portion of the claim can be settled. 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Failure to Comply Failure to protect Medicare’s interests can result in legal action against the beneficiary, attorney, insurance carrier, self-insured employer/insurer. If legal action is necessary, Medicare may recover double damages. With the new legislation, the fines include $1,000/day/claimant in addition to other penalties under the law. 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Workers Compensation 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. (Centers) 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

CMS Review Threshold It is not in Medicare's best interest to review every WC settlement nationwide in order to protect Medicare's interests per 42 CFR (Ref: 7/23/01 Memo Q1(c)) A WCMSA is not necessary when resolution of the WC claim leaves the medical aspects of the claim open. A WCMSA may be submitted to CMS for review in the following situations: The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; OR The claimant has a "reasonable expectation" of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000. (Centers) 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

The Unknown Will CMS have a review threshold for liability, no fault, auto, and self insured? If so, will the thresholds be the same as they are for Workers’ Compensation? What will the turn-around-time be from submission to CMS review/determination? 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Medicare Set Aside 2008 Update
GENEX MSA Program Medicare Set Aside 2008 Update 1/4/2008 © 2007 GENEX Services, Inc. All rights reserved

GENEX Services Offers:
Social Security & Medicare Status Determination Medicare Set-Aside Cost Projection Rush Projection Projection Update Comprehensive Drug Utilization Review Medicare Set-Aside Submission Medicare Set-Aside Guarantee 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Social Security & Medicare Status Determination
Verification of Social Security and Medicare entitlement status Written opinion on whether the case is appropriate for submission to CMS 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Medicare Set-Aside Cost Projection
Status determination Medicare Set-Aside recommendation Cost projection of Medicare covered costs Recommendation for frequency and amount of periodic payments when structured settlement is being utilized Determine life expectancy or rated age Medicare conditional payment claim identification Rush Turn Around of the Cost Projection Projection Update (only applies 6 months after original projection completion) 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Drug Utilization Review
The pharmacist will provide a comprehensive evaluation regarding: Medication name and strength Quantity supplied Days supplied Physician Diagnosis Procedures relating to the injury Diagnostics relating to the injury The pharmacist will also make recommendations regarding the medication(s) over the claimant's life expectancy. 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Medicare Set-Aside Submission
Recommendation regarding need for Medicare Set-Aside Proposal submission and approval Social Security and Medicare status determination Medicare conditional payment claim identification Recommendation for frequency and amount of periodic payments when structured settlement is being utilized Projection of Medicare allowable costs Completion of Medicare Proposal Submission of Proposal to Medicare Follow-up with Medicare and negotiation until approval is obtained 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Medicare Set-Aside Guarantee
MSA2 – The GENEX Medicare Set-Aside Guarantee Program. MSA2 provides a guarantee that the Centers for Medicare and Medicaid Services (CMS) will approve the allocation. Should CMS determine a higher set-aside amount, GENEX will pay the difference. GENEX’s Medicare Set-Aside Services assist Workers’ Compensation Carriers in meeting this obligation by determining appropriate set-aside amounts and securing Medicare approval. GENEX also offers MSA2 – our Medicare Set-Aside Guarantee Program. MSA2 provides a guarantee that the Centers for Medicare and Medicaid Services (CMS) will approve the allocation. Should CMS determine a higher set-aside amount, GENEX will pay the difference. Over 25 years experience in life care planning and case management GENEX utilizes only Medicare trained allocators supervised by life care planners Attorney involvement Highly qualified Social Security Representatives 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

GENEX Advantages GENEX’s skilled, experienced, knowledgeable experts will prepare your Medicare Set Aside GENEX will complete a cost analysis of the future medicals associated with your claim GENEX provides a Life Care Planner to review all Medicare Set Asides at no extra cost to you GENEX provides attorneys, on staff, to assist with any questions you have at no extra cost to you 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Turn-Around-Times Eligibility verification weeks Cost projection 30 days (upon receipt of all documentation required) All projections are provided to the carrier for initial approval Submission to CMS - 2 weeks Submission Approval – 8 to10 weeks depending on CMS turn around 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Make an MSA Referral By Fax By & Web MSA Coordinator obtains all necessary authorizations from the Applicant. Needed for a referral are: Request for Service (RFS) Medical Records Last two years of prescriptions Claim billing history By Mail Customer Referrals Dedicated Referral Address: 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Key Differentiators In-house attorney involvement on every case who are involved in the allocation and submission - no additional fees. Certified LCP reviewing all cases Core competency Aggressive approach GENEX has over 10 years experience dealing with the Social Security Administration. 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

In Review Medicare has been a secondary payer source since 1980. New legislation adds fines to primary payers that do not take Medicare’s interest into account when settling medicals on a file. GENEX is here to assist you! 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

Thank you! Cited Works 1) Centers for Medicare & Medicaid Services. U.S. Department of Health & Human Services. < (accessed Jan 17, 2008) 2) GovTrack.us. S th Congress (2007): Medicare, Medicaid, and SCHIP Extension Act of 2007, GovTrack.us (database of federal legislation) < (accessed Jan 17, 2008) 3) “S.2499 Medicare, Medicaid, and SCHIP Extension Act of 2007.” OpenCongress. 01/17/08. (accessed 01/17/08) < 1/4/2008 © 2008 GENEX Services, Inc. All rights reserved

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