have undertaken a comprehensive effort to protect Medicare's interests and to recover money owed to Medicare for conditional payments made, as well as to prevent the shifting of future medical expenses from the primary payer to Medicare. If a primary payer is settling future medical benefits for a "qualified" individual, CMS requires that an arrangement be made for future injury-related Medicare allowable medical expenses to be set aside from the settlement. This arrangement must be approved by CMS.

An individual is "qualified" if:

1. The Individual is a Medicare
recipient at the time of settlement,
regardless of the amount of
settlement.

- or -

2. The individual is not yet
receiving Medicare benefits but
the following two prong test is met:

THE TOTAL AMOUNT OF THE SETTLEMENT
IS $250,000.00 or over.

- and -

IT IS REASONABLY EXPECTED THAT THE INDIVIDUAL
WILL BECOME A MEDICARE RECIPIENT WITHIN 30 MONTHS
OF THE SETTLEMENT.

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Note: Per the CMS memo of July 11, 2005, Medicare’s interest must be considered when settling a workers’ compensation claim even if the review thresholds have not been met. This memo further identifies the responsibilities of protecting Medicare’s interest even if the settlement amount is under $250,000, if there is a reasonable expectation that the claimant may be entitled to Medicare within 30 months.