MSAs and Liability Cases

Although no statutory or regulatory authority requires Medicare set-aside arrangements (MSAs) in third party liability settlements, confusion continues as to whether and when MSAs are necessary and/or appropriate for such cases.

Although their objectives and target audiences are different, the National Academy of Elder Law Attorneys (NAELA) and the American Bar Association (ABA) have each recently issued recommendations addressing MSAs and liability cases.

MSAs are administrative and funding mechanisms utilized in certain categories of settlements to protect Medicare's interests as "secondary payer" under the Medicare Secondary Payer (MSP) statute. MSA objectives include:

• Protecting Medicare from erroneous billings;
• Releasing settlement participants from Medicare liability;
• Providing a settlement-funding vehicle;
• Utilizing Medicare properly to limit settlement costs.

Although Federal law does no define MSAs, or mandate specific types of MSA funding mechanisms, CMS (the responsible federal agency) has established certain basic requirements for workers compensation MSAs (WCMSA) in a series of memoranda beginning in 2001:

• Maintain an interest-bearing account;
• Reimburse Medicare provider bills at appropriate fee schedules for Medicare allowable services;
• Submit an annual accounting of expenses to the lead CMS contractor.

In addition, the CMS WCMSA memoranda create both an advantage and a problem for using structured settlements to fund WCMSAs:

• October 15, 2004 Memorandum - CMS sets forth a "set-off" method for calculating present value that establishes an inherent cost advantage for annuity funding as opposed to lump sum funding for many WCMSAs.
• August 20, 2008 Memorandum - CMS encourages the submission of annuity quotes with rated ages to establish life expectancy with requirements that have proven burdensome for both structured settlement consultants and annuity providers.

Meanwhile, the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) requires liability insurers to determine the Medicare status for all claimants and to report all claims involving a Medicare beneficiary to CMS when those claims are resolved - or face a civil penalty of $1000 per day per unreported claim.

• On November 9, 2010, CMS delayed the submission deadline for liability insurance claim reports from the first calendar quarter of 2011 to the first quarter of 2012.
• MMSEA does not address the need for MSAs in liability cases and CMS has not offered any related uniform or formal guidance.

Within this confusing legal environment, where liability insurers and attorneys must still decide how best to comply with the MSP act in liability cases without over-reacting and establishing an MSA unnecessarily, NAELA and the ABA have each issued recent recommendations.

NAELA published its recommendations on October 27, 2010 as part of a Medicare Set-Aside Task Force Report approved by NAELA's Board of Directors. In addition to recommendations, the NAELA Task Force Report includes findings and legal resources. NAELA's recommendations are intended for special needs and elder law attorneys handling personal injury settlements involving the MSP program and include two caveats:

• "The requirement for future medical expenses set-asides in tort cases is not as clear as it is in WC cases"; and
• "Some Medicare regional offices will not consider MSP set-asides in tort cases. Cases in which the above advice should be communicated to clients should be limited to those cases with large settlement/awards based on specific estimates and evidence of the costs of future medical services."

S2KM summary of NAELA's recommendations:

• Document any advice and counseling about the appropriateness of MSAs for specific cases.
• Advise personal injury (PI) clients to set-aside an equivalent amount of funds for future Medicare-related medical expenses in a self administered MSA.
• Warn PI clients that the Medicare Secondary Payer Act (MSP) applies to all tort settlements and that CMS considers PI plaintiffs to have an obligation to protect Medicare's interests in coordinating future benefits.
• Advise PI clients to consider MSAs with applications for approval to CMS in cases with large settlement/awards based on specific estimates and evidence of the costs of future medical services.
• Be mindful under state law of an attorney's duty to protect a client’s liability recovery from incorrect claims and unnecessary charges.
• The NAELA Public Policy Committee and Medicare Task Force should continue:
  • Dialogue about MSAs with appropriate CMS officials;
  • Educating NAELA members about MSAs through NAELA publications; and
  • Communicating NAELA’s position on MSAs to appropriate PI lawyer trade associations.

Unlike NAELA, the ABA recommendations, approved during the ABA's 2011 Midyear Meeting, are addressed to the United States Congress and urge Congress to amend the MSP Act. The ABA recommendations resulted from resolutions adopted by the ABA's Tort Trial and Insurance Practice Section (TIPS) which also included a list of historical findings:

• "RESOLVED, That the American Bar Association urges Congress to acknowledge that there is no regulatory or statutory basis for Medical Set Asides for third party liability settlements, judgments or awards under the Medicare Secondary Payer Act and provide clear, predictable, and consistent procedures for the submission, uniform determination, and timely approval of any third party medical set aside settlement proposals (MSASP) voluntarily submitted to the Centers for Medicare & Medicaid Services (CMS) in response to the non-binding recommendations of CMS.
• "FURTHER RESOLVED, that legislation to accomplish these goals should incorporate the following principles:
  1. Acknowledge that there are not statutory and regulatory requirements for determining Medical Set Aside payments and the process for approving claims subject to the Medicare Secondary Payer Act for third party liability claims.
  2. Exempt from review by CMS all settlements in which there are no legal obligations to pay medical benefits.
  3. Establish an appeals process that must be completed by CMS within 690 days of request by the claimant, insurer, or their representative.
  4. Prohibit CMS from seeking additional moneys from the settlement proceeds after review and/or appeals processes have been concluded.
  5. Prohibit recovery thresholds for MSASP that are linked to predetermined economic indices.
  6. Prohibit recovery thresholds for MSASP that are linked to predetermined economic indices.
  7. Establish a 30 day deadline by which CMS must respond in writing of its acceptance of the proposed MSASP.
  8. Require CMS to timely (“timely” means within 60 days the information must be delivered to the patient and patient’s lawyers) and reasonably provide a detailed list of any payments it made and/or may make a claim for set aside for, and if it does not, cannot collect or require a set aside for that patient.
  9. Prohibit the “certification” or claim of specialization by any private individual or person or government entity of a process, practice or individual in the determination of MSASP.
  10. Prohibit the use of Social Security numbers and Health Card Numbers in the MSASP reporting process."

For additional analysis of MSAs, MMSEA and the MSP Act, see Chapter 15 in "Structured Settlements and Periodic Payment Judgments".