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Medicare Set Aside

What is a Medicare Set-aside Arrangement?

It is an allocation of money, set-aside from the total settlement money for future medical care and prescription drugs, to pay for care related to the WC injury that would otherwise be a Medicare covered item.

What is the Medicare Secondary Payer Statute (MSP)?

Federal legislation designed to prevent the shifting of responsibility for medical treatment from a primary payer or insurance carrier to Medicare.

Why should your settlements take into account the Medicare Secondary Payer Statute?

All parties in a Workers' Compensation (WC) case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare's interests when resolving WC cases that include future medical expenses. If Medicare finds that its interests have not been protected in a WC settlement, fines and penalties may be charged to the claimant, third party recipients, attorneys, and the carriers. In fact, the carrier may incur double indemnity.

How do we protect Medicare's interest?

The recommended method to protect Medicare's interests is a Workers' Compensation Medicare Set-aside Arrangement (WCMSA), which allocates a portion of the WC settlement, for future medical expenses. The amount of the set aside is determined on a case-by-case basis and should be reviewed by CMS, when appropriate.

When should the parties in a WC settlement think about the MSP?

The answer is: in every settlement the MSP should be considered. A Medicare Set-Aside Arrangement (MSA) may not be needed in every situation; however, there are situations when an MSA needs to be pre-approved by the Center for Medicare and Medicaid Services (CMS). Parties in a settlement that occur prior to obtaining a pre-approved MSA, when the CMS requires review and approval of the MSA, are at the greatest risk for exposure.

How do I know when to have an MSA completed?

Prior MSA approval by CMS is needed in the following scenarios:

  • If the claimant is on Medicare and the settlement amount is greater than $10K
  • If there is a reasonable expectation that the claimant will become a Medicare recipient within 30 months of the proposed settlement date and the total settlement amount is greater than $250K.

Contact AdvoCase's Medicare Set-aside Certified Consultant staff to assist you in answering your questions and setting up your Medicare Set-Aside Arrangement.

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