Medical Expense Management Inc.
Medicare Set-Asides - Items Needed for MSA Referral



CMS/Medicare General Release
PDF | Word

The Center for Medicare and Medicaid Services (CMS) will only review and approve MSAs that meet the following criteria:

(1) In which the injured individual is currently eligible for Medicare—and the settlement amount exceeds $25,000; or
(2) If settlement value is over $250,000 (inclusive of indemnity, attorney fees and costs) AND the injured individual is reasonably expected to become entitled to Medicare within 30 months (e.g. the injured individual is currently receiving Social Security Disability benefits).

Items Required to Complete Medicare Set-Aside:

  1. First Notice of Injury/Loss
  2. Last 2-3 years of medical payouts
  3. Last 2-3 years of medical records
  4. Any medical documents stating Maximum Medical Improvement
  5. Rated Age (can be obtained from us or your annuity broker)
  6. Completed Referral Form (online, faxed, or mailed)
  7. Life Care Plan/Medical Cost Projection (if available)
  8. Pharmacy Summary (if available)
  9. Court orders (if applicable)
  10. Estimated settlement amount
  11. Claimant's Medicare or Social Security Disability status

Items needed if CMS approval is requested:

In addition to the above requirements, we will need the following items to obtain CMS for approval of the MSA:

  1. CMS/Medicare General Release signed by claimant
  2. Method of administering the MSA (self or professional)
  3. Method of funding MSA (annuity or lump sum)
Complete an online Worker's Compensation Referral Form >

Complete an online Liability Referral Form >