In Pennsylvania, what happens to Medicare Set Aside Funds

You may have heard about Medicare Set Aside agreements when it comes to Workers Compensation lump sum settlements.  They are complex and confusing too many.  Let me try and help explain a little about this complex area of law.

First, when is a Medicare Set Aside agreement required as part of a structured workers compensation settlement?  Generally, with a worker’s compensation settlement, federal law prohibits Medicare from paying for injury-related medical expenses or medications that an employer is responsible to pay.  In essence, other insurance coverage exists for those medical expenses.  To achieve that purpose, Federal government regulations require that a portion of settlement funds be “set-aside” in an account to pay for future medical expenses related to the work injury. So what specifically triggers this process?  Here are the general criteria when a settlement should be submitted for CMS review.

CMS will only review new WCMSA proposals that meet the following criteria:

  • 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/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00

So, what is the important words in here — “is” and reasonable (more…)

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