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:
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:
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.