THE “INS” AND, MORE COMMONLY THE “OUTS,” OF WORKERS’ COMPENSATION MEDICARE SET-ASIDE ARRANGEMENTS
By
EPS
As most individuals involved in the workers’ compensation field on both sides of the aisle have learned by now, the interests of Medicare must be considered in certain circumstances where the parties intend to resolve the applicant’s right to future medical care for their industrial injuries.  As a full-service law firm that performs analyses and submissions to the Centers for Medicare and Medicaid Services (CMS) for our clients, we have observed several reoccurring questions that arise regarding when a Workers’ Compensation Medicare Set Aside Arrangement (WCMSA) is necessary and the process of obtaining CMS approval of the proposed set aside.  Below, you will find some of the most common questions and their answers. 

A.    Why Do We Need to Consider a Medicare Set-Aside?

Medicare does not pay for medical treatment that arises from work-related injuries.  Therefore, sufficient funds must be “set aside” to cover a worker’s future medical care needs for the work injury.  Once the WCMSA amount is exhausted, Medicare will pick up coverage, thus giving Medicare an interest in ensuring that the funds set aside for an applicant’s future medical care needs will be sufficient to cover all anticipated industrial medical care expenses. 

B.     When are Medicare Set-Asides and CMS Approval Required

A WCMSA is only necessary in cases involving a settlement of the applicant’s future medical care.  Further, CMS has established certain threshold criteria that must be met before they will review a WCMSA regarding adequacy.  The criteria are:

1. The applicant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000.00.
 
2. The applicant has a “reasonable expectation” of Medicare enrollment within 30 months of the settlement date (i.e. they have applied for Social Security benefits or the individual is 30 months away from being Medicare eligible) and the anticipated total settlement is expected to be greater than $250,000.00. 

Next >>
Home l Attorney Profiles l Firm History l Publications l News and Events l Practice Areas l Contact
contact@esp-law.com