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.

TESTIMONIALS

I wanted to pass my highest recommendation to Synergy who we routinely get involved in cases when Medicare issues come up, especially when dealing with Medicare Set Asides. Synergy went beyond the call of duty in a recent case that was settled and dealt one-on-one with our clients and their family. They spent time on the phone with them to be sure they got all their questions answered and did a fantastic job dealing with Medicare.

J. Daniel Clark
Clark Martino, P.A.

"I just wanted to say thanks to you and the entire Synergy Settlement Services team for helping us put together a series of structured settlements and special needs trusts in two complex cases involving significant recoveries. As always, your accessibility, guidance and expertise on a whole host of post-settlement issues is very much appreciated and valued, particularly with respect to the often confusing topic of Medicare set asides. I look forward to our continued collaboration on cases in the future and am very appreciate of the first rate service your company continues to provide to our clients."

Stephan Le Clainche
Formerly of Babbitt, Johnson, Osborne & Le Clainche

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