What Is the Medicare Set-Aside Requirement (MSA)?

Posted on Monday, July 20th, 2015 at 9:53 am    

Part and parcel of any settlement calculation of a workers’ compensation claim is figuring the costs of future medical care. Ideally, the calculations will be perfect and the money the insurance company pays for your medical care matches what you actually need during your lifetime. Often, though, the calculation is not correct and you end up needing more money for future medical bills than you planned.

If you are already a Medicare Recipient, or if you are close to becoming a Medicare recipient—for instance if you are above age 63 or you have applied for and are receiving Social Security Disability, then the law says you cannot ‘double dip.’ You cannot obtain money from workers comp to cover your future medical care and then turn around and expect Medicare—and the U.S. Taxpayer—to pay for that same care.

To make sure Medicare has some protection against paying for every future work injury medical bill when the workers compensation insurance carrier really should pay, in some cases workers’ compensation and Medicare law require that the parties to a workers’ compensation settlement prepare a Medicare Set-Aside (MSA) report. The report is usually several pages and is prepared by companies who analyze your medical treatment and doctor recommendations to make an estimate of the cost of your future care related to your work injuries. It attempts to calculate, in detail, the worker’s future medical bills. It includes an overall monetary figure. The report is usually prepared at the expense of the defense side.

As an example, a 35 year-old worker may have a severe back injury that prevents him/her from working. The worker figures that he needs a certain sum for the medications and treatments needed to keep the back from getting worse. 35 years later, it turns out there’s a new medical procedure that will cure or vastly improve the back pain. The worker would like to get Medicare to pay for the procedure because the money from the settlement has run out.

In the example of the 35-year-old who wants Medicare to pay for his/her back surgery at age 70, Medicare will look to see if an MSA report was required, if it was properly prepared and if it was properly submitted at the time of the worker’s compensation settlement – 35 years earlier. If the report was supposed to be filed and it wasn’t, then Medicare would likely disapprove the medical procedure because Medicare’s interests were not properly taken into account.

In some cases, for instance if you are a current Medicare recipient, it is required that the MSA be sent to a special office at Medicare first for approval. Once approved, assuming you follow the Medicare rules for properly putting aside your funds in an appropriate account this should offer good protection against running into any problems with Medicare going forward.

North Carolina and Virginia Injured Worker Attorney Joe Miller Knows Medicare Set Asides

At some point, the worker may outlive the settlement money’s ability to pay for future care related to his or her work injuries. To make sure the injured worker is able to then utilize Medicare benefits to take over paying for the care related to his or her work injuries, the Worker’s Compensation and Medicare requirements both have to be met. Virginia and North Carolina attorney Joe Miller knows both sets of requirements. He’ll review the laws with you. Please give us a call at Joe Miller Law at 888-694-1671 and ask for me, Joe Miller, or email me at jmiller@joemillerinjurylaw.com