,,ii #aafth ,,congress #b;d ,session ,s4 #dgcd ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,september #bd1 #bjbj,mr4 ,portman 7for himself and ,mr4 ,cardin7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act to provide for the application of ,medicare secondary payer rules to certain workers' compensation settlement agreements and qualified ,medicare set-aside provisions4 #a4 ,short title ,this ,act may be cited as the ,coordination ,of ,medicare ,payments and ,workers' ,compensation ,act or the ,,comp ,act4 #b4 ,application of ,medicare secondary payer rules to certain workers' compensation settlement agreements 7a7 ,secondary payer provisions for workers' compensation settlement agreements ,section #ahfb of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7 is amended-- 7#a7 in subsection 7b77#b77;,a77ii71 by inserting subject to subsection 7p71 after 7ii72 and 7#b7 by adding at the end the following new subsection3 7p7 ,definitions ,for purposes of this subsection and subsection 7q73 7#a7 ,compromise agreement ,the term compromise agreement means a workers' compensation settlement agreement that-- 7,a7 applies to a workers' compensation claim that is denied or contested1 in whole or in part1 by a workers' compensation payer involved under the workers' compensation law or plan applicable to the jurisdiction in which the agreement has been settled2 and 7,b7 does not provide for a payment of the full amount of benefits sought or that may be payable under the workers' compensation claim4 7#b7 ,workers' compensation claimant ,the term workers' compensation claimant means a worker who-- 7,a7 is or may be covered under a workers' compensation law or plan2 and 7,b7 submits a claim or accepts benefits under such law or plan for a work-related injury or illness4 7#c7 ,workers' compensation law or plan 7,a7 ,in general ,the term workers' compensation law or plan means a law or program administered by a ,state or the ,united ,states to provide compensation to workers for a work-related injury or illness 7or for disability or death caused by such an injury or illness71 including the ,longshore and ,harbor ,workers' ,compensation ,act 7#cc ,u4,s4,c4 #ija-idd1 #idh-iej71 chapter #ha of title #e1 ,united ,states ,code 7known as the ,federal ,employees ,compensation ,act71 the ,black ,lung ,benefits ,act 7#cj ,u4,s4,c4 #ica et seq471 and part ,c of title #d of the ,federal ,coal ,mine and ,safety ,act 7#cj ,u4,s4,c4 #ija et seq471 but not including the ,act of ,april #bb1 #aijh 7#de ,u4,s4,c4 #ea et seq47 7popularly referred to as the ,federal ,employers' ,liability ,act74 7,b7 ,inclusion of similar compensation plan ,such term includes a similar compensation plan established by an employer that is funded by such employer or the insurance carrier of such employer to provide compensation to a worker of such employer for a work-related injury or illness4 7#d7 ,workers' compensation payer ,the term workers' compensation payer means1 with respect to a workers' compensation law or plan1 a workers' compensation insurer1 self-insurer1 employer1 individual1 or any other entity that is or may be liable for the payment of benefits to a workers' compensation claimant pursuant to the workers' compensation law or plan4 7#e7 ,workers' compensation settlement agreement ,the term workers' compensation settlement agreement means an agreement between a claimant and one or more workers' compensation payers that-- 7,a7 forecloses the possibility of future payment of some or all workers' compensation benefits involved2 and 7,b7 7i7 compensates the claimant for a work-related injury or illness as provided for by a workers' compensation law or plan2 or 7ii7 eliminates cause for litigation involving issues in dispute between the claimant and payer4 4 7b7 ,satisfaction of secondary payer obligations ,section #ahfb of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey71 as amended by subsection 7a71 is amended by adding at the end the following new subsection3 7q7 ,treatment of ,medicare set-,asides under workers' compensation settlement agreements 7#a7 ,satisfaction of secondary payer obligations 7,a7 ,full satisfaction of claim obligations 7i7 ,in general ,if a workers' compensation settlement agreement1 related to a claim of a workers' compensation claimant1 includes a ,medicare set-aside 7as defined in subparagraph 7,b77i771 such set-aside shall satisfy any obligation with respect to payments reasonably expected to be made under subsection 7b77#b77;,a77ii7 with respect to such claim4 7ii7 ,rule of construction ,nothing in this section shall be construed as requiring the submission of a ,medicare set-aside to the ,secretary4 7,b7 ,medicare set-aside and ,medicare set-aside amount defined ,for purposes of this subsection3 7i7 ,medicare set-aside ,the term ,medicare set-aside means1 with respect to a workers' compensation settlement agreement1 a provision in the agreement that provides for a payment of a lump sum1 an annuity1 a combination of a lump sum and an annuity1 or other amount that is in full satisfaction of the obligation described in subparagraph 7,a7 for items and services that the workers' compensation claimant under the agreement received or is reasonably expected to receive under the applicable workers' compensation law4 7ii7 ,medicare set-aside amount ,the term ,medicare set-aside amount means1 with respect to a ,medicare set-aside1 the actual dollar amount provided for in clause 7i74 7#b7 ,medicare set-aside 7,a7 ,satisfaction of ,medicare set-aside ,for purposes of this subsection1 a ,medicare set-aside meets ,medicare secondary payer obligations if the ,medicare set-aside amount reasonably takes into account the full payment obligation described in paragraph 7#a77;,a71 while meeting the requirements of subparagraphs 7,b7 and 7,c7 and is determined based on the following3 7i7 ,the illness or injury giving rise to the workers' compensation claim involved4 7ii7 ,the age and life expectancy of the claimant involved4 7iii7 ,the reasonableness of1 and necessity for1 future medical expenses for treatment of the illness or injury involved4 7iv7 ,the duration of and limitation on benefits payable under the workers' compensation law or plan involved4 7v7 ,the regulations and case law relevant to the ,state workers' compensation law or plan involved4 7,b7 ,items and services included ,a ,medicare set-aside-- 7i7 shall include payment for items and services that are covered and otherwise payable under this title as of the effective date of the workers' compensation settlement agreement and that are covered by the workers' compensation law or plan2 and 7ii7 is not required to provide for payment for items and services that are not described in clause 7i74 7,c7 ,payment requirements 7i7 ,required application of workers' compensation law and fee schedule 7,i7 ,in general ,except in the case of an optional direct payment of a ,medicare set-aside made under paragraph 7#e77;,a71 the set-aside amount shall be based upon the payment amount for items and services under the workers' compensation law or plan and applicable fee schedule 7effective as of the date of the agreement74 7,,ii7 ,workers' compensation fee schedule defined ,for purposes of this subsection1 the term workers' compensation fee schedule means1 with respect to a workers' compensation law or plan of a ,state or a similar plan applicable in a ,state1 the schedule of payment amounts the ,state has established to pay providers for items and services furnished to workers who incur a work-related injury or illness as defined under such law or plan 7or in the absence of such a schedule1 the applicable medical reimbursement rate under such law or plan74 7ii7 ,optional proportional adjustment for compromise settlement agreements ,in the case of a compromise settlement agreement1 a claimant or workers' compensation payer who is party to the agreement may elect to calculate the ,medicare set-aside amount of the agreement by applying a percentage reduction to the ,medicare set-aside amount for the total settlement amount that could have been payable under the applicable workers' compensation law or similar plan involved had the denied1 disputed1 or contested portion of the claim not been subject to a compromise agreement4 ,the percentage reduction shall be equal to the denied1 disputed1 or contested percentage of such total settlement4 ,such election may be made by a party to the agreement only with the written consent of the other party or parties to the agreement4 7#c7 ,optional process for approval of ,medicare set-asides 7,a7 ,optional prior approval by ,secretary ,a party to a workers' compensation settlement agreement that includes a ,medicare set-aside may submit to the ,secretary the ,medicare set-aside amount for approval4 7,b7 ,notice of determination of approval or disapproval ,not later than #fj days after the date on which the ,secretary receives a submission under subparagraph 7,a71 the ,secretary shall notify the parties to the workers' compensation settlement agreement in writing of the determination of approval or disapproval4 ,if the determination disapproves such submission1 the ,secretary shall include with such notification the specific reasons for the disapproval4 7#d7 ,appeals 7,a7 ,in general ,a party to a workers' compensation settlement agreement that is dissatisfied with a determination under paragraph 7#c77;,b71 upon filing a request for reconsideration with the ,secretary not later than #fj days after the date of notice of such determination1 shall be entitled to-- 7i7 reconsideration of the determination by the ,secretary 7with respect to such determination72 7ii7 a hearing before an administrative law judge thereon after such reconsideration2 and 7iii7 judicial review of the ,secretary's final determination after such hearing4 7#e7 ,administration of ,medicare set-aside provisions 7,a7 ,optional direct payment of ,medicare set-aside amount 7i7 ,election for direct payment of ,medicare set-aside amount ,effective #cj days after the date of enactment of this subsection1 with respect to a claim for which a workers' compensation settlement agreement is or has been established1 a claimant or workers' compensation payer who is party to the agreement may elect1 but is not required1 to transfer to the ,secretary a direct payment of the ,medicare set-aside amount4 ,the parties involved may calculate the ,medicare set-aside amount of such set-aside using any of the following methods3 7,i7 ,in the case of any ,medicare set-aside of a compromise settlement agreement under paragraph 7#b77;,c77ii71 the amount calculated in accordance with such paragraph4 7,,ii7 ,in the case of any ,medicare set-aside1 the amount based upon the payment amount for items and services under the workers' compensation law or plan and fee schedule 7effective as of the date of the agreement7 in accordance with paragraph 7#b77;,c77i77,i74 7,,iii7 ,in the case of any ,medicare set-aside1 the payment amount applicable to the items and services under this title as in effect on the effective date of the agreement4 ,such transfer shall be made only upon written consent of the other party or parties to the agreement4 7ii7 ,election satisfying liability ,an election made under clause 7i71 with respect to a qualified ,medicare set-aside1 shall satisfy any payment1 in relation to the underlying claim of the related workers' compensation settlement agreement1 required under subsection 7b77#b7 to be made by the claimant or payer to the ,secretary4 7,b7 ,election of professional or beneficiary self-administration of ,medicare set-aside payments ,nothing in this subsection or subsection 7p7 prohibits an individual from electing to utilize professional administration services or to self-administer payments of their ,medicare set-aside in accordance with existing law4 7#f7 ,treatment of ,state workers' compensation law ,for purposes of this subsection and subsection 7p71 if a workers' compensation settlement agreement is accepted1 reviewed1 approved1 or otherwise finalized in accordance with the workers' compensation law of the jurisdiction in which such agreement will be effective1 such acceptance1 review1 approval1 or other finalization shall be deemed final and conclusive as to any and all matters within the jurisdiction of the workers' compensation law1 including-- 7,a7 the determination of reasonableness of the settlement value2 7,b7 any allocations of settlement funds2 7,c7 the projection of future indemnity or medical benefits that may be reasonably expected to be paid under the ,state workers' compensation law2 and 7,d7 in the case of a compromise agreement1 the total amount that could have been payable for a claim which is the subject of such agreement in accordance with paragraph 7#b77;,c77ii74 4 7c7 ,conforming amendments ,section #ahfb7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7b77 is amended-- 7#a7 in paragraph 7#b77;,b77ii71 by striking paragraph 7#i7 and inserting paragraph 7#i7 and subsections 7p7 and 7q72 7#b7 in paragraph 7#b77;,b77iii7-- 7,a7 in the first sentence1 by striking ,in order to recover payment and inserting ,subject to subsection 7q71 in order to recover payment2 and 7,b7 in the third sentence1 by striking ,in addition and inserting ,subject to subsection 7q71 in addition2 and 7#c7 in paragraph 7#c77;,a71 by striking ,there is established a private cause of action and inserting ,subject to subsection 7q71 there is established a private cause of action4 7d7 ,modernizing terminology for purposes of ,medicare secondary payer provisions ,section #ahfb7;b77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7b77#b77;,a77 is amended by striking workmen's compensation law or plan and inserting workers' compensation law or plan each place it appears4 7e7 ,limitation on liability ,the parties to a workers' compensation settlement agreement which met the provisions of section #ahfb7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7b77 on the effective date of settlement shall be accepted as meeting the requirements of such section notwithstanding changes in law1 regulations1 or administrative interpretation of such provisions after the effective date of such settlement4 7f7 ,effective date ,the amendments made by this section1 unless otherwise specified1 shall apply to a workers' compensation settlement agreement with an effective date on or after ,january #a1 #bjba4