Answers to Your Questions About Medicare Set-Asides

A Medicare set-aside adds a new layer of complexity to your workers’ compensation claimIf you have been seriously injured in a workplace accident, then the cost of your future medical treatment is likely a serious concern. It is a concern, however, that may be addressed during your workers’ compensation settlement.

One way to address the concern of future medical costs is through a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA). Below are answers to four common questions about Medicare set-asides that may help you better understand this potential benefit.

What Is a Workers’ Compensation Medicare Set-Aside?

A workers’ compensation Medicare set-aside is part of a workers’ compensation settlement. It is money that is paid separately by the workers’ compensation insurer for medical costs projected in the future for your work injury that would have otherwise been paid by Medicare.

Since the law prohibits shifting the burden from workers’ compensation to Medicare for your work injury, Medicare could deny payment for medical treatment related to your work injury if your Medicare set-aside is not properly exhausted first. A WCMSA may either be paid in lump sum or be established as a structured arrangement, where payments are made on a defined schedule to cover expenses projected for future years. If it is structured, an initial deposit is required to cover the first surgical procedure or replacement and two years of annual payments. Following the initial payment, additional funds are typically paid on an annual basis for a length of time equal to the injured worker’s life expectancy at the time of settlement.

When is a Workers’ Compensation Medicare Set-Aside Needed?

Any workers’ compensation settlement that includes an amount for future medical expenses must take Medicare’s interest into account. If a proposed WCMSA meets the thresholds below, then the proposal should be submitted to the Centers for Medicare and Medicaid Services (CMS) for approval:

  1. The injured worker is already receiving Medicare, and the total workers’ compensation settlement amount is more than $25,000; or
     
  2. The injured worker is reasonably expected to be a Medicare beneficiary in the next 30 months, and the total settlement including expected future medical costs and disability/lost wages is expected to be more than $250,000.

The Centers for Medicare and Medicaid Services (CMS) may approve the amount requested for a Medicare set-aside, increase the amount, or decrease the amount based on the information that is provided with the submission.

How Can I Get a Fair Medicare Set-Aside?

In most cases in which a Medicare set-aside is needed, the workers’ compensation insurer will hire a vendor to come up with a WCMSA proposal. The vendor will review the available medical records and project what your future medical treatment will cost over the rest of your life. It is very important to have an experienced workers’ compensation attorney review the proposed Medicare set-aside to make sure that it properly accounts for all medical treatment you are going to need for your work injury. If your case is large enough to require a WCMSA, you really should have an attorney working with you and not attempt to settle your case on your own.

What Should I Do If I Receive a Medicare Set-Aside?

Once you receive a Medicare set-aside, it is important that you keep the money in a separate interest bearing bank account. You will be required to file an annual statement with CMS. If you follow all of the rules and you are a Medicare beneficiary, then Medicare will cover any additional medical costs you incur if your set-aside money runs out.

If you are considering settling your workers’ compensation claim, especially if a Medicare set-aside is involved, it is important to work with an experienced workers’ compensation lawyer who knows how to maximize your recovery and protect your legal rights. If you have been hurt in Georgia and you would like to learn more, please start a free live chat with us now.