Statutory Authority:
- 42 U.S.C. §1395 y(b)(2) (MSP making Medicare a secondary payer).
- 42 C.F.R. § 411.45, §411.50 and §411.100 (Medicare may make payment if the primary plan is not expected to make payment in 120 days).
- 42 C.F.R. §411.24(b). (CMS may disregard a settlement and seek reimbursement of medical expenses from a primary payer).
- 42 C.F.R. §411.24(e) & (g) (CMS may seek reimbursement from any entity responsible for making primary payment).
- SMART Act of 2012 (H.R. 1845)
- PAID ACT (H.R. 8900) – The PAID Act amends 42 U.S.C § 395y(b)(8)(G), Testing window was from September 12 to December 10, 21 and went Live on December 11, 2021.
Guidelines issued by the Centers for Medicare and Medicaid Services (CMS):
- CMS Memorandum dated 7/23/01, “Patel Memo”, Establishing WCMSAs.
- CMS Memorandum dated 4/22/03, Questions and Answers.
- CMS Memorandum dated 5/23/03, Questions and Answers Regarding the Review Threshold.
- CMS Memorandum dated 5/7/04, Administrative Fees/Expenses and/or Attorney Costs Cannot be Charged to WCMSA.
- CMS Memorandum dated 10/15/04, Question and Answers Regarding Pricing Method, Self Administration and Structured Settlements.
- CMS Memorandum date 7/11/05, Frequently Asked Questions.
- CMS Memorandum dated 12/30/05, Part D and WCMSAs Questions and Answers. (RESCINDED).
- CMS Memorandum dated 4/25/06, Establishing New Workload Review Threshold of $25,000.00 Total Settlement.
- CMS Memorandum dated 7/24/06, Questions and Answers for Part D and Workers’ Compensation Medicare Set-aside Arrangements, supersedes CMS Memorandum dated 12/30/05.
- CMS Memorandum dated 8/25/08, Policies Regarding the Pricing of Implantable Devices and Rescinding CMS Memorandum dated 7/11/05 regarding Termination of a WCMSA Account.
- CMS Memorandum dated 4/3/09, Pricing of Prescription of Drugs.
- CMS Memorandum dated 5/14/10, Clarifying Part D Covered Drugs and Rated Age Language.
- CMS Memorandum dated 6/8/10, Clarifying the CMS Memorandum dated 5/14/10 Rated Age Language.
- CMS Memorandum dated 5/11/11, Reiterating Guidance on WCMSA Review Thresholds.
- CMS Memorandum dated 9/30/11 (Safe harbor for liability cases where treating physician certifies no future treatment is needed).
- Reference guide 3.5
Self-Administration Guidance:
- WCMSA Self-Administration Website
- Self-Administration Toolkit Version 1.3
- Account Expenditure for Structured Annuity (Attestation Letter)
- Account Expenditure for Lump Sum Account (Attestation Letter)
- Transaction Record Sample
- General Pricing on Outpatient Procedures
- Items & Services Not Covered Under Medicare
- Medicare Coverage Database for Coverage Determinations issued by Medicare
- Is your test, item, or service covered?
Miscellaneous:
Medicare Appeals Process
- Part A and B (Fee for Service) Appeals Process
- Medicare Advantage Plan (Part C) Appeals Process
- Part D (Drug Plan) Appeals Process
- HHS Primer: The Medicare Appeals Process
- Amount in Controversy Requirements
- Form DAB-101 Request for Review of ALJ Medicare Decision
- Medicare Parts A & B Appeals Process
- FAQS: Medicare Appeals
- FAQs: Requesting an ALJ Hearing
- ALJ Appeal Status Lookup Page
- Forms Needed for Your Level 3 Medicare Appeal
- Contact Info for the Office of Medicare Hearings and Appeals
