Does Your Client Require a Medicare Set-Aside Arrangement?

A Medicare set-aside arrangement is a fiscal agreement that assigns a portion of a plaintiff’s personal injury awarded settlement to fund their future medical needs (medical visits, surgeries, medications, etc.). These medical services must be directly related to the injury the plaintiff suffered in order to receive the settlement and the funds must strictly be spent to cover the costs of the services prior to Medicare covering any of these services. In other words, Medicare is the secondary payer after the set-aside arrangement funds have been exhausted.

Consult With Set-Aside Experts

When a plaintiff is awarded a settlement, understanding Medicare set-aside requirements and determining the amount of funding that should be allocated into this arrangement is best left to a Medicare set-aside services specialist. No two Medicare set-aside arrangements are exactly the same and each case needs to be evaluated on an individual basis. In this brief article, our settlement experts will discuss Medicare’s requirements for claimants to be considered for a workers’ compensation set-aside arrangement.

Medicare Set-Aside Requirements

When an awarded settlement exceeds $25,000, if the claimant is eligible for Medicare, they are required to create a set-aside account. However, if the claimant is not eligible for Medicare, they are only required to create a set-aside account if the settlement exceeds $250,000. Generally, claimants that are 65 years of age or older require a set-aside account; however, claimants can be qualified for Medicare before the age of 65 if they are disabled or have been paid Social Security disability income for at least two consecutive years.

Following Rules and Regulations

It’s important that claimants are aware that their future Medicare benefits can be compromised if they fail to comply with the strict regulations set forth by their Medicare set-aside arrangement. This includes the following rules:

  • Claimants can only spend their set-aside arrangement funds on medical expenses related to the injury they received the settlement money for.
  • All documents related to these medical expenses must be preserved.
  • Annually, these expenses need to be reported to Medicare.

With many complex regulations, it’s important to contact a settlement expert that specializes in Medicare set-aside services. Our experienced settlement professionals can focus on your client’s Medicare requirements and ensure that they are in compliance with the rules and regulations set forth by Medicare. If you need assistance developing and overseeing a Medicare set-aside arrangement, contact us today.

For more information or to schedule a consultation, please submit our contact request form.

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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Hector J. Lombana
Gamba & Lombana

When we face difficult post resolution issues, we turn to Synergy. They provide us with the necessary expert advice about Medicare compliance, preservation of public benefits, lien resolution and settlement planning. We don’t need to go anywhere else, they are the experts when it comes to the case after the case. All of those sticky issues, they easily navigate and let us focus on other issues.

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