MSA Addendum
Beneficiary Name:_____________________________________ Date:__________________________
Establishment of Medicare Set-Aside Sub-trust. A portion of the funds transferred to the Trustee are
allocated as Medicare Set-Aside funds from a Third Party Liability Settlement where the settlement
includes payment for an item or service covered by Medicare. Please provide the applicable final
settlement agreement with Joiner Agreement. The main account shall be known as beneficiary’s
“General Fund” and Medicare Set-Aside Account shall be called “Sub-trust”
1. In addition to the Declaration of Trust of WisPACT Trust I, the following shall also be in effect:
a. During the lifetime of <BENEFICIARY’S NAME>, both the corpus of and the income from the
Sub-Account composed of or derived from the Medicare Set Aside Allocation shall remain
segregated as a part of the Sub-trust. The Trustee shall segregate the Sub-trust from the
General Fund.
b. The Sub-trust share shall be administered as a Medicare Set Aside Arrangement in
accordance with the provisions of 42 U.S.C. §1395y, Exclusions From Coverage And Medicare
As Secondary Payor, (Section 1862 of the Social Security Act, as amended by the Medicare
Prescription Drug, Modernization and Improvement Act of 2003) and the regulations and policy
memoranda applicable to and interpreting the same, being 42 C.F.R. §411.20 et seq. and
memoranda issued by the Centers for Medicare and Medicaid Services (CMS), which provision,
regulations and policy are herein referred to collectively as the Medicare Secondary Payor Law.
c. Neither such segregation nor payment of medical expenses from the
Sub-trust shall limit or
impair the absolute discretion provided Trustee nor cause any portion of the Trust to be considered
available to <BENEFICIARY’S NAME>, or subject to <HIS/HER> control. The trustee’s absolute
discretion over the Sub-trust, however, is subject to the following:
i. Payment of Certain Medical Expenses If and As Required For Medicare Benefits
During the lifetime of <BENEFICIARY FIRST NAME>, the trustee shall distribute both the
corpus of and the income from the Sub-trust as may be necessary for payment of
Beneficiary’s medical services and supplies that would otherwise be reimbursable under
Medicare, if but only if (a) such payments are necessary under the Medicare Secondary
Payor Law, and (b) such payments shall be prudent in the discretion of the Trustee after
considering all other benefits to which <BENEFICIARY’S NAME> shall be entitled.
Such
medical services and supplies are herein referred to as “eligible injury-related medical
expenses”. The Trustee shall not be liable for making a distribution or payment for medical
supplies, care, prescription drugs or treatment which is later determined to be a type that is
not reimbursable by Medicare.
In no event shall the assets of the General Fund be deemed available for
Beneficiary’s Medicare reimbursable expenses.
payment of the
ii. Administrative Fees, Costs, and Expenses Related to the Sub-trust
Administrative fees, costs, and expenses related to the Sub-trust shall not be paid from the
Sub-trust or its income. Any such fees, costs, and expenses associated with the
maintenance, management, and administration of the Sub-trust, including but not limited to
charges from fiduciary services of the Trustee or Medicare claims and payments
administrator, shall be paid or reimbursed exclusively from the General Fund. The Trustee
is authorized to pay administrative fees, costs, and expenses related to the Sub-trust from
the General Fund.
iii, Trustee Fees
Any Trustee may compensate itself when it is serving as Trustee of the General Fund or
Sub-trust and may reimburse itself for reasonable Trust expenses. Provided however, in no
event shall payment of compensation or reimbursement to the Trustee be paid from the
Sub-trust to the extent prohibited by the Medicare Secondary Payor Law. The trustee is
authorized to pay its compensation or reimbursements from the General Fund.
iv. Calculation of the Medicare Set Aside
The calculation of the Medicare Set Aside Allocation is not the responsibility of the
trustee of WisPACT. The responsibility of the calculation of the Medicare Set Aside
allocation will be the beneficiary’s. The Trustee or WisPACT shall not be liable for
actions of the beneficiary or any independent third-parties retained by the beneficiary.
d. Accountings
The Trustee shall render accountings in accordance with WisPACT’s ordinary and usual practices for
accountings to beneficiaries, and at least annually or as otherwise required by law.
e. Administration
The Trustee shall have all powers granted by law or other provisions of this instrument. The Trustee
shall have the authority to consult with and hire third party administrators, experts, and consultants to
comply with the investment, expenditure, reporting requirements, and any other requirements under
Medicare laws. Notwithstanding any other provision to the contrary, in no event shall fees for the
third party administrators, experts, consultants, and other fees and expenses of the Sub-trust be paid
from the Sub-trust. The fees, costs and expenses of such administrators, experts, and consultants,
if any, shall be borne by the General Fund (but not the Sub-trust). Such fees, costs and expenses
shall not reduce or be paid from or as a part of the compensation due the Trustee.
The Trustee may rely upon the instructions and advice of such administrators, experts, and
consultants regarding disposition of the Trust as to eligible injury-related medical expenses, and
payments and distributions from the Trust, made in accord with such instructions and advice of such
administrators, experts, and consultants shall be conclusively deemed authorized and proper. The
Trustee shall not be liable for actions of an agent or administrator to whom a function is delegated
under this provision if the Trustee exercises reasonable care in selecting such agent or administrator.
f. Distribution of the Sub-trust Upon Death of Beneficiary
Unless sooner terminated by the exhaustion of corpus, upon the death of Beneficiary, the
trust shall be distributed as follows:
Sub-
i. If the settlement document which provided for the payment of Medicare Set Aside
funds includes a provision requiring that remaining funds upon the death of the
Beneficiary be returned to the payor of such funds, such terms shall apply to final
distribution of the Sub-trust.
The instrument is titled __________________________ and dated __________________
ii. If the settlement document which provided for the award and payment of Medicare
Set Aside funds does not require that the remaining assets upon the death of the
Beneficiary be returned to the payor of such funds, the remaining assets shall be added
to the remaining General Fund and shall be distributed in accordance with Article II of the
contribution agreement and Article XIV of the WisPACT Trust I.
State of Wisconsin
]
]
County of ___________________]
ss.
The Sub-Account Applicant hereby requests
creation of a MSA Sub-trust in WisPACT Trust I.
This Instrument was personally acknowledged Signed: ________________________________________
And signed before me at _________________
Sub-trust Applicant
By ___________________________________
__________________________ who appeared
If the Beneficiary or Beneficiary’s Representative
Before me on ___________________, 20____
is not the Applicant, he/she indicates his/her
understanding of the acknowledgments he/she
__________________________
initialed and documents, by signing,
Notary Public, State of Wisconsin
if applicable.
Signed: ________________________________________
Name: ________________________________ Sub-Account Beneficiary/Representative
My commission expires: __________________
Title: □ Guardian
□ Agent under D.P.O.A.
Declaration of Attorney
□ the Applicant
□ the Sub-trust Beneficiary
□ the Sub-trust Beneficiary’s Legal Representative
□ __________________________________________
With respect to this MSA Addendum and related documents establishing a General Fund and Sub-trust
in WisPACT Trust I for Beneficiary. I have reviewed the master trust, this MSA Addendum and all related
documents as to form and content and discussed them with my client(s).
I, a licensed attorney, represent
Check all that apply
Dated: ___________________________
Firm: __________________________________
By: __________________________________
Print Name of Attorney
__________________________ _
Address, Phone No. and E-mail
_______________________________________
_______________________________________
_______________________________________
Attorney Bar Number:
_____________________________
The Applicant's attorney, or, if none, the Beneficiary's attorney agrees to file copies of these
documents with government agencies as required for Public Benefits that Beneficiary is now or may
be receiving in the future and provide evidence of same to WisPACT, Inc. and the Trustee. He or she
also agrees to continue his or her representation until a determination has been made about the effect
of this General Fund and Sub-trust on Beneficiary's Public Benefits after such documents have been filed
and that he or she will notify WisPACT, Inc. and the Trustee of any adverse ruling and timely appeal
same.
Signed on behalf of WisPACT, Inc. this _____ day of ____________,20____
WisPACT, Inc.
Signed By:
________________________________________
Title:
_________________________________________
The Appointment of trustee of the sub-trust created by the foregoing instrument
Is accepted on behalf of Trustee this _____ day of _________________,20______
ASSOCIATED TRUST COMPANY, N.A.
Signed By:
_________________________________________
Title:
_________________________________________