When the Beneficiary Fails to Meet Either Waiver Criterion under Section

50.16 – When the Beneficiary Fails to Meet Either Waiver Criterion under Section 1870(c) (Rev. 12438; Issued: 01-04-24; Effective: 02-06-24; Implementation: 02-06-24) When the beneficiary requests a waiver, but does not meet either of the two stated criteria, the request for waiver should be denied. The following examples illustrate such circumstances: a) Facts: The beneficiary broke a leg and is now unable to work. Medicare’s conditional payments total $7,000. The beneficiary received a settlement of $20,000. After reducing Medicare’s claim to allow for beneficiary procurement costs, Medicare should recover $4,667. The total beneficiary monthly income is $1,004 (interest income and social security benefits), with monthly expenses of $585. Out-of-pocket incurred expenses total $870 and the beneficiary has requested a full waiver. Analysis: Wavier criteria is not met because the beneficiary has not shown that daily living expenses could not be met, nor that repayment would be unfair. This determination is based upon the information provided, which documents that the beneficiary is able to meet daily living expenses, and has excess funds ($285 excess per month), even without the settlement received. Moreover, the beneficiary received a large enough settlement to pay the non-covered out-of-pocket expenses and to repay Medicare without incurring a financial hardship. Repayment under these circumstances is equitable. Action: Waiver request is denied. b) Facts: The beneficiary was unemployed before injury that triggered Medicare conditional payments. However, the accident has reduced the probability that the beneficiary will ever be able to work again. Medicare’s recovery is $11,000. No attorney was used in procuring the settlement, nor were there other beneficiary procurement costs. Therefore, no beneficiary procurement costs were subtracted from the amount of Medicare’s recovery. The beneficiary received a $55,000 settlement. Documented out-of-pocket medical expenses equal $10,000. Monthly expenses are $2,068 and monthly income is $1150 ($771 social security benefits, $344 unemployment, and $35 interest income). Analysis: The beneficiary has a monthly shortfall of $918, which appears to constitute a financial hardship. However, this financial hardship existed before the accident. Repaying Medicare must be the circumstance that causes financial hardship. Preexisting financial hardship alone is not a sufficient reason to grant waiver. Additionally, after repaying Medicare and paying for out-of-pocket expenses, the beneficiary retains $33,221 of the settlement proceeds. Repayment of Medicare’s claim will not deprive the beneficiary of any valuable right or put the beneficiary in a worse position than before the accident. For this reason, repaying Medicare is not against equity and good conscience. Action: Waiver request is denied.