The Medicare Secondary Payer statute applies to claims that are 1) being settled, 2) where future medical care is a component of the settlement and 3) wherein the claimant is a “qualified individual”.
Qualified Individual means:
“Reasonable Expectation” of Medicare eligibility means:
The current CMS review thresholds for Workers’ Compensation cases are as follows:
Again, “Reasonable expectation” includes, but is not limited to: situations where the claimant has applied for social security disability(SSD); claimant has been denied SSD but anticipates appealing the decision or re-filing for SSD; claimant is 62 years and 6 months old(meaning they will be eligible for Medicare in 30 months based on age); End Stage Renal Disease.
CMS is on record as stating that these review thresholds are simply agency “workload review” thresholds and are NOT “safe harbors”. It is CMS’ position that their interests must always be considered and protected.