Workers Compensation Medicare set-aside agreements (WCMSS) are financially-related agreements where a portion of the workers' settlement can be used for medical care for injuries to workers or for other medical care. These funds will be drained before Medicare can reimburse patients for their injuries. The federal law enforcing the secondary payor (MSP) of Medicare provides for a statutory duty to protect the rights of Medicare to redress the case of wrongful death. Among those recommended strategies for protecting Medicare's interests are WCMSAs.
The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future. Medicare reserves the right to have reporting for up to the entire settlement amount on medicare covered treatments before Medicare agrees to begin covering injury-related bills. If the injured party doesn't properly manage their MSA account, Medicare will deny paying for their injury-related treatment until the reporting is corrected.
42 CFR 411.14 – Lump sum payments. Lumpsum commutation benefits. If lump-sum compensation award specifies the sum paid will reimburse the individual for the necessary future medical bills due to a work-related illness or injury. Medicare payments for such services will not be reimbursed until medical costs related to such injuries or disease exceed the total amount. (b) (3) The agreement obligates Medicare to pay medical costs and expenses if the amount paid is more than equal in terms of the lump-sum payments.
WC case costs will remain incurred by Medicare, but Medicare will pay Medicare for the remainder. 41 CFR 41.46 and 42.47 provide a requirement in WCs where Medicare's interest is included in the case of unforeseen health care costs. In the event of WC settlement, the individual should consider Medicare in the best interest of the individual.
After receiving the required details, Medicare set aside reports will be sent out within a week. Rush reports may be accessed by request at a charge.
CMS recommends that parties to a WC settlement set aside funds, otherwise known as Workers' Compensation Medicare Set-aside Arrangements (WCMSAs) for all future medical services related to the WC injury or illness/disease that would otherwise be reimbursable by Medicare.
All parties in a workers' compensation case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare's interests when resolving cases that include future medical expenses.
To the extent a WC settlement meets both of the criteria (i.e., the settlement is greater than $250,000 AND the claimant is reasonably expected to become a Medicare beneficiary within 30 months of the settlement date), then a CMS-approved Medicare set-aside arrangement is appropriate.
if you are receiving Medicare or can be expected to receive Medicare, you may need to create a special kind of trust, called a Medicare Set-Aside, to reimburse the government for future medical expenses related to your injury. (Many people younger than age 65 receive Medicare through their receipt of Social Security Disability Insurance (SSDI) benefits.)
the administrator of the Medicare Set-Aside trust may use the funds only to pay for medical care related to your personal injury, leaving Medicare or your private insurance free to provide coverage for medical expenses that are not related to your injury. Medicare Set-Asides have been used for years in workers' compensation cases, and the federal government has an extensive set of reporting and monitoring rules in place for those cases.