Workers Compensation Medicare Set Aside

What Does CMS Consider When Reviewing WCMSA’s?

As a personal injury attorney, you work hard for your clients. You assess the fine details of their case, you go through the proper channels, and you reach a settlement. While this is a great victory for your client, there’s still more challenging work to do. If the settlement is with your client’s workers compensation insurance and there is an expectation of future medical payments, Medicare must be considered. According to law, Medicare is considered a secondary payer and their interests must be protected when considering future medical payments. Settlement funds must be exhausted before Medicare can start paying. The recommended way for accomplishing that is through the use of a Workers Compensation Medicare Set-Aside (WCMSA).

A WCMSA is a financial agreement in which a portion of the funds from a workers compensation settlement is set aside to pay for future medical expenses. Once this pot of money has been used, Medicare will step in to pay for medical expenses. WCMSA arrangements may be reviewed by the Centers for Medicare & Medicaid (CMS) services for approval. While this is not a required step, it is highly recommended to ensure a proper amount is being allocated and to avoid penalties.

CMS has a list of criteria that they review to determine if a WCMSA is “reasonable” per their requirements. Below is a synopsis of several noteworthy requirements.

  • What is your client’s Medicare entitlement: Certain conditions are more expensive than others. This includes patients 65 and older, those with End-stage Renal Disease, or patients with a disability. Costs associated with these conditions are considered.
  • How severe is the injury or illness: Medical costs differ depending on whether a full or partial recovery is expected.
  • Where does your patient live: Does he or she live in an assisted living center or at home? Who is expected to pay for assisted living or in-home care? These questions are considered by CMS when evaluating a WCMSA arrangement.
  • Is the settlement lump sum or structured?

For more information or to schedule a consultation, please submit our contact request form or call (877) 242-0022.

Disclaimer: The information contained in this article is for general educational information only. This information does not constitute legal advice, is not intended to constitute legal advice, nor should it be relied upon as legal advice for your specific factual pattern or situation.

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"Coincidentally, on the day of a recent Synergy Seminar on Medicare & ERISA lien resolution I received a letter on an ERISA lien. This letter followed much back and forth between myself and the recovery vendor for BCBS. Despite my efforts they were adamant there would be no (zero)(zilch)(nada) reduction and provided case law to support their position. I tried Synergy’s Lien Resolution Services since I had just heard their Director of Lien Resolution speak. Synergy got them to reduce their claim by a third in less than ten (10) days. The result was quick and the fee very reasonable. If you have a tough ERISA lien and your typical efforts don’t work, give Synergy a try."

Michael S. Smith, Esq.
Lesser, Lesser, Landy & Smith, PLLC

"Synergy is an invaluable partner in the mediation process. They have extensive expertise in Medicare, Medicaid and Structured Settlements and the ability to explain the impact of these complex concepts to my clients in simple, clear and understandable language. This allows me to focus on obtaining the best possible result in the settlement process."

Michael J. Winer, Esq.
President Florida Workers Advocates (FWA)

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