Question: Annie, in ExamWorks’ last webinar, Marty and Christie discussed CMS’ updated guidance for cases that don’t meet review thresholds. I’ve heard from some people that if an individual has ever applied for SSDI, they have a reasonable expectation of Medicare enrollment within 30 months. Is that accurate? Can you recap CMS’ updated guidance and what constitutes reasonable expectation of Medicare enrollment within 30 months?

Answer: It is not accurate to say that if an individual has ever applied for Social Security Disability Insurance (SSDI) benefits, they have a reasonable expectation of Medicare enrollment within 30 months. While they may, it is not a given, and that is an important distinction for the parties to make since it ultimately informs how best to satisfy the Medicare Secondary Payer (MSP) Statute. With any statute, regulation, or agency guidance, we must read it within context.

Let’s examine the guidance set forth by Medicare in its Workers’ Compensation Medicare Set-Aside Allocation (WCMSA) Reference Guide. Medicare outlines its workload review criteria in Section 8.1 and indicates it will review a proposed WCMSA amount when the following workload review thresholds are met:

Medicare goes on to document that a claimant has a reasonable expectation of Medicare enrollment within 30 months if any of the following apply:

• • The claimant has applied for Social Security Disability Benefits;
  • The claimant has been denied Social Security Disability Benefits but anticipates appealing that decision;
  • The claimant is in the process of appealing and/or re-filing for Social Security Disability benefits;
  • The claimant is 62 years and 6 months old; or
  • The claimant has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.

An application for SSDI alone may be sufficient, but if meant to be determinative in the “reasonable expectation” analysis, then it would obviate the need for bullet points two (anticipated appeal) and three (has appealed or is in process of appealing or re-filing) above. The “reasonable expectation” analysis is based on the claimant’s actions and/or present intentions, so individual context and facts matter. In fact, there are situations where an individual will not qualify for SSDI despite an application and despite any anticipated or actual appeal. Consider the following in order to receive SSDI and Medicare benefits:

• An individual must have lawfully paid SS taxes into the Social Security program. If an ineligible party submits an application, the mere fact they applied does not give them a “reasonable expectation.” Unless and until that individual meets the eligibility criteria, they will never be eligible for SSDI or Medicare despite their application.
• An individual must have worked a requisite number of quarters depending on their age in order to qualify. In general, to get disability benefits, one must meet two different earnings tests: 1) a recent work test, based on the age at the time they became disabled; and 2) a duration of work test to show that they worked long enough under Social Security (i.e., paid the requisite payroll taxes). If an 18 year-old with a one year work history applies for SSDI benefits, they will not qualify since they must have worked a minimum of six quarters to meet the duration of work test. With a one year work history, that individual has only worked four quarters. Unless and until they meet the earnings tests, they will never be eligible for SSDI or Medicare despite the application and without regard to any appeal.

Information about one’s earnings, including quarters worked, and overall SSDI application/appeal status may be obtained using our Social Security Verification (SSV) service whereby we collect and confirm needed information directly from the claimant’s local Social Security Administration office. ExamWorks Clinical Solutions offers an all-inclusive portfolio of Medicare compliance solutions in addition to the SSV service and we welcome the opportunity to work with you.