Montana Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA)
If you have been seriously injured on the job or developed a work-related disease, chances are your medical expenses are going through the roof. Seeing those medical bills pile up doesn’t make your life easier, not to mention that you may be out of work for weeks, months, or possibly even years.
Fortunately, there’s a way to cover your expenses related to the work injury or illness—you can seek workers’ compensation benefits through your employer’s insurance provider.
But imagine if you settle your workers’ comp claim and later discover unexpected expenses related to the same injury or illness? This can be a frustrating situation. And given that you have already settled your claim all you get from the employer’s insurance company is a shrug of the shoulders.
But there may be a way to prevent this scenario and ensure your future medical needs are protected. That’s where a Worker’s Compensation Medicare Set-Aside (WCMSA) arrangement comes in handy.
Our workers’ compensation attorneys at Gerstner Adam Law help hard-working people in Billings and other parts of Montana, including Sidney, Glendive, and Miles City, ensure that they have proper medical coverage for as long as it’s necessary.
What Is a Workers’ Compensation Medicare Set-Aside Arrangement?
A Workers’ Compensation Medicare Set-Aside Arrangement, which is commonly referred to as just a Medicare Set-Aside or WCMSA, is an agreement between Medicare and you (as the Medicare beneficiary) that sets aside a portion of funds from the workers’ comp settlement to cover future medical services that (a) are related to the injury or illness and (b) would normally be paid by Medicare.
Under this agreement, you must deplete all the allocated funds before Medicare resumes paying for the care needed.
Why Do You Need Medicare Set-Aside?
Many people don’t understand why they need a WCMSA when settling their workers’ compensation. The reason lies in Medicare’s Secondary Payer (MSP) laws. Even if you have Medicare coverage or will soon be eligible for this fee-for-service health insurance program, Medicare can refuse to cover your medical needs related to the workers’ compensation claim in the absence of a WCMSA arrangement.
That’s because Medicare doesn’t have the primary payment responsibility to pay for services that are the responsibility of other coverage, such as workers’ compensation.
When Does Medicare Agree to Review a WCMSA Proposal?
With a Medicare Set-Aside, you can have peace of mind knowing that your future benefits won’t be disrupted. However, not everyone is eligible to request such an arrangement with Medicare. That’s because Medicare has limitations on when it will review WCMSA proposals. According to the Centers for Medicare & Medicaid Services (CMS), Medicare agrees to review Medicare Set-Aside proposals only when any of the following is true:
The injured worker, who is already on Medicare, has a workers’ compensation settlement with the total amount that exceeds $25,000; or
The injured worker has a workers’ compensation settlement with the total amount that exceeds $250,000 and is expected to be enrolled in Medicare within 30 months.
If none of the above-mentioned circumstances apply to you, you may still be eligible for benefits. Our workers’ compensation attorneys at Gerstner Adam Law can explain how.
How Is Medicare Set-Aside Funded?
When an injured worker and the employer’s workers’ comp insurance provider sign a settlement agreement that includes a WCMSA arrangement, the approved-upon Medicare set-aside will be funded with either:
A single lump sum payment intended to pay for all future medical expenses; or
Annual installment payments.
Generally, lump-sum arrangements are appropriate for smaller amounts (e.g., less than $10,000). Structuring a WCMSA arrangement as annual installment payments is usually agreed upon by the parties when the projected medical expenses are greater than $10,000.
How Are Medicare Set-Aside Funds Administered?
Medicare requires that all funds as part of Medicare Set-Asides are deposited into separate bank accounts that cannot be used for anything other than medical expenses covered by the WCMSA arrangement. Medicare’s administration and accounting requirements are rather strict, which is why injured workers have an obligation to prepare and submit detailed reports to Medicare outlining how the set-aside funds were spent annually.
What Happens if You Ignore Medicare’s Interests in Your Workers Compensation Settlement?
Failure to consider Medicare’s interests when settling your workers’ compensation claim can have dire consequences. One of them is that Medicare will refuse to pay for your medical expenses until you exhaust the entire amount of the settlement.
The Centers for Medicare & Medicaid Services (CMS) can pursue legal action to recover any payments it made for medical services from any person or entity that received “primary” payments. By ignoring Medicare’s interests when settling your workers’ compensation claim, you’re making the life of your future self harder.
At Gerstner Adam Law, we can explain if you need a Medicare Set-Aside in your settlement and help you arrange one.
Considering a Medicare Set-Aside in Your Workers’ Compensation Settlement?
WCMSA arrangements are critical components of workers’ compensation settlements. This is true for both current and future Medicare beneficiaries. If you have been injured at work or suffered occupational disease, our attorneys at Gerstner Adam Law can help ensure that you settle for a fair amount and take all the necessary nuances into consideration, including the need for a Medicare Set-Aside, when settling your claim.
Contact our office today to schedule your free case evaluation. Located in Billings, Montana, we serve clients throughout Glendive, Miles City, and Sidney.