What criteria does Medicare use to determine whether the amount of a lump sum or structured settlement has sufficiently Aconsidered@ Medicare=s interests?
A45. The following criteria is used by CMS in evaluating the amount of a proposed Medicare Set-aside to determine whether there has been an attempt to shift liability for the cost of a work or accident related injury or illness to Medicare. Specifically, is the amount allocated for future medical expenses and prescription drug therapy charges reasonable? If Medicare has already made conditional payments their repayment also has to be taken into account. 1. Date of entitlement to Medicare. 2. Basis for Medicare entitlement (disability, ESRD or age). If the injured party has entitlement based on disability and would also be eligible on the basis of ESRD, this should be noted since the medical and prescription expenses would be higher. This would also be true for an injured party who is over 65 but had been entitled prior to attaining that age. 3. Type and severity of injury or illness. Obtain diagnosis codes (ICD) so injury or illness related expenses can be identified. Is full or partia
