How Much Money in a Workers Compensation
Settlement is the “Medicare Set Aside”?
A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is a financial agreement that is required by law in all worker comp cases where there will be ongoing medical treatment. This arrangement “sets aside” a portion of an employee’s workers’ compensation settlement money into a separate account – and keeps it to pay for future medical services related to the workers’ compensation injury or illness.
The injured employee’s WCMSA funds that have been “set aside” must be “used up” before Medicare will pay for any medical treatment related to the workers’ compensation injury, illness, or disease.
Workers Compensation Medicare Set Aside Must be Reasonable
The amount of your workers’ comp settlement money that must put in a separate fund earmarked for the WCMSA is not a “set amount” – it is determined on a case-by-case basis. Workers Comp laws require that a “reasonable” amount be set aside for future medical expenses.
The following criteria are considered when reviewing the Workers’ Compensation Medicare Set-aside Arrangement (WCMSA), and determining what is a “reasonable” amount to withhold.
(1.) The employee’s date of entitlement to Medicare –
Obviously, the sooner the employee would be entitled to Medicare, the more money that must be withheld.
(2.) The employee’s basis for Medicare entitlement –
Certain disabilities have greater ongoing medical costs than others. For example, the medical expenses of a claimant with End Stage Renal Disease requiring daily dialysis will be much higher than an employee with a head injury.
(3.) The type and severity of the injury or illness –
A diagnosis code should be obtained, so injury or illness related expenses can be identified. Whether a full or partial recovery is expected – as well as the projected time frame of recovery will be considered.
(4.) Age of the injured employee –
Younger employees will have a longer lifespan and therefore need medical treatment longer than an older injured worker. Evaluation of whether the condition will shorten the life span is also looked at.
(5.) Payments already made by Medicare –
Any conditional payments made by Medicare while awaiting the settlement must also be included in the WCMSA and repaid to Medicare.
(6.) Where the injured employee lives –
Whether the claimant is staying at home, living in a nursing home, or receiving assisted living care, etc. will affect future Medicare costs and will be considered in determining the amount withheld for the Workers’ Compensation Medicare Set-aside Arrangement (WCMSA).
Each case Workers’ Compensation Medicare Set-aside Arrangement (WCMSA) will be evaluated on its own merits. For comparison purposes, the average annual amounts of Medicare Part A and Part B spent on a disabled person with a similar condition in a similar residence may be considered. Input from a medical consultant will typically be sought when determining whether the amount of the lump sum or structured settlement has sufficiently taken Medicare’s interests into account.
Experienced Workers’ Compensation Medicare Set-aside Attorneys
It is very important to consult with an attorney specialized in Workers Comp “Medicare Set-Aside” (WCMSA) immediately if you have a workers’ compensation claim. You need an attorney who can advocate for your rights, and ensure enough money for your future medical needs is set aside – while also ensuring that you obtain the other maximum benefits to which you are entitled.
Our experienced Workers Comp attorneys have established Workers Comp Medicare Set-Aside trust accounts for hundreds of clients – ensuring that their medical needs are always taken care of. Call us today for a FREE consultation today.