Joinder Agreement Special Needs Trust Foundation Self-Settled Master Trust Medicare Set-Aside (Msa) Supplement Form (Page 2 of 2) in pdf

MSA Vendor shall perform all accounting and reporting functions necessary to comply with policies

established by the Centers for Medicare and Medicaid Services (CMS). MSA Vendor shall refuse any

request for disbursement from a Trust Beneficiary’s MSA funds for services neither related to the

insurance settlement, nor otherwise covered by Medicare. Any payments made in error that should have

otherwise been made from the trust shall be repaid to the MSA from the trust.

MSA Vendor:

The SNTF may retain or terminate an MSA Vendor without obtaining the consent of the

Grantor, the Beneficiary, or his or her Beneficiary Advocate.

The MSA Vendor shall be responsible for evaluation and determination of disbursement

requests from funds within the trust identified as MSA funds in accordance with policies established by

the CMS to ensure that Medicare remains secondary payer in situations related to the underlying

insurance settlement. MSA Vendor shall not be responsible for any investment or physical possession of

the MSA funds and shall perform solely administrative functions related thereto. MSA Vendor shall

request payments made from MSA funds directly by the Trustee to medical service providers who

rendered services deemed appropriate to be paid with MSA funds.

A MSA Vendor may resign or may be removed by the SNTF upon thirty (30) days

written notice, and, if applicable, subject to confirmation by any court retaining jurisdiction over a

Beneficiary’s trust affected by the resignation or removal. If a MSA Vendor resigns or is removed, the

SNTF shall select a Successor MSA Vendor and give written notice thereof to the Beneficiary and to their

Beneficiary Advocate. The Successor MSA Vendor shall be selected by the SNTF as soon as practicable

after notice of resignation is received by the SNTF or notice of removal of the MSA Vendor is provided

by the SNTF. Any MSA Vendor that resigns or is removed shall serve until another person or entity

accepts being appointed Successor MSA Vendor. Any Successor MSA Vendor shall act without any

liability for the acts or omissions of any predecessor MSA Vendor. If required by court order, the

appointment of a MSA Vendor or any successor MSA Vendor shall be done only with court approval.

Distribution Upon Termination of Trust:

Medicare requires that an MSA account remain open for a reasonable period following the death

of a Beneficiary in order to allow time enough for final claims to be made by medical service providers.

Once it has been determined that all MSA claims have been paid from the MSA designated funds, the

remaining funds shall become incorporated into Beneficiary’s individual sub-account as part of the

Remainder Amount. Final Accounting shall be made by MSA Vendor to CMS at that time. Expenses for

MSA Vendor to wind-up MSA portion of the trust may be paid prior to the payment of state

reimbursement of medical expenses.

IN WITNESS WHEREOF, the undersigned Beneficiary or his/her legal representatives or designees has

reviewed and signed this Medicare Set-Aside Supplement to the Joinder Agreement, understands it, and

agrees to be bound by its terms, and the Trustee has accepted and signed this Medicare Set-Aside

Supplement to the Joinder Agreement this _______ day of _______________, 20____.

______________________________________

BENEFICIARY’S LEGAL REP., TITLE

BENEFICIARY

ATTACH SUPPORTING DOCUMENTATION

Approved and accepted:

____________________________________________

_______________________________

TRUSTEE/SNTF Corporate Officer

DATE

Joinder Agreement Special Needs Trust Foundation Self-Settled Master Trust Medicare Set-Aside (Msa) Supplement Form Page 2

Related Articles

Related forms

Related Categories