What Is a Medicare Set-Aside?

When you’ve been injured on the job, you could be eligible for workers’ compensation, which allows you to cover the cost of treating your serious and painful injuries. However, many people don’t realize that Medicare may require you to use a Workers’ Compensation Medicare Set-Aside agreement, or (WCMSA). But what is a WCMSA, exactly?

About Workers’ Compensation Medicare Set-Asides

A WCMSA is a financial agreement that “sets aside” a portion of your workers’ compensation settlement, in order to pay for future medical services related to the injury. This can apply to any claim that falls under the workers’ compensation system, as well as anyone who is currently benefitting from Medicare, or will receive Medicare in the future (which can include people under age 65 who receive Social Security Disability Benefits.)

Functioning similarly to a trust, a WCMSA agreement contains funds you can use to pay for medical treatment. However, these specific funds must be completely used before Medicare will pay for any further treatment related to your injury. Ultimately, WCMSA agreements serve to protect Medicare’s interest, as Medicare can legally refuse to pay for future treatment related to your work-related injury until the settlement is exhausted.

Seeking CMS Approval for a WCMSA

In some cases, you will need to get approval from Centers for Medicare and Medicaid Services (CMS) in order to receive your WCMSA. Failing to get CMS approval can cause many long-term complications. If the parties involved in a workers’ compensation settlement stipulate a WCMSA amount, but do not receive CMS approval, then CMS is not bound by the set-aside amount, and it can refuse to pay for future medical expenses related to the injury. This is true even if the expenses would ordinarily have been covered by Medicare. However, if CMS does approve the WCMSA amount and the account is later appropriately expended, Medicare will pay.

CMS will review a proposed WCMSA amount when the following review thresholds are met:

  • The claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or
  • The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date, and the anticipated total settlement amount for future medical expenses and disability or lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00.

If you have any other questions related to workers’ compensation, Medicare, or Medicare Set-Asides, our qualified Central Florida workers’ comp attorneys at Van Dingenen Law can assist you. We’ve been fighting exclusively on behalf of injured workers and their families since 2003, and we are passionate about providing our clients with the legal guidance and advocacy they need to recover from their injuries.

Contact us at (407) 967-5377 for a free consultation!

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