April 6, 2021 • ComplianceEducation

Determining Medicare Covered Items & Services for Your Medicare Set Aside

Pursuant to the Medicare Secondary Payer (MSP) provisions, following certain types of settlements which resolve medicals, Medicare may not pay for medical expenses related to your workers' compensation injury.

When settling a workers’ compensation claim that resolves future medicals, all parties in a workers’ compensation case must ensure Medicare’s interests are considered. This is achieved by setting aside a portion of the settlement funds in a Medicare Set Aside Account (MSA) to pay for medical treatment related to your work injury for services that are covered by Medicare.

If you have an MSA, ensuring every expense paid for with those funds is Medicare-covered is complicated.

  • How do you know which of the services you are receiving are Medicare covered benefits?
  • Is your office visit covered?
  • Are your x rays covered?
  • And what about durable medical equipment?

These questions aren’t always easy to answer.

Over 60% of the total Medicare beneficiary population's claims are managed by a Medicare Administrative Contractor (MAC).1 A MAC is a private health insurer that has been awarded a geographic area of Medicare beneficiaries’   claims payments.

When Medicare makes a coverage decision, it applies on a national level to every state, also known as a National Coverage Determination (NCD). However, MAC’s have the responsibility of establishing Local Coverage Determinations (LCD’s). If Medicare has not made a NCD, this means based on LCD’s, an item or service may be covered in one state, but not another at the discretion of the MAC’s own set of guidelines that are encompassed under Medicare coverage.

To decide whether an item or service is a Medicare benefit, both NCD’s and LCD’s must be taken into consideration.

There are currently 12 MACs for administering Part A (hospital/facility) and Part B (professional) services. There are 4 MAC’S that administer Medicare’s DME/Orthotics/Prosthetics program. When considering Medicare benefits, and subsequently what your MSA covers, not only do we need to review Medicare guidelines, but we also need to review guidelines that each of the MACs have in place.

This is especially important when considering new or emerging procedures. LCD’s are more common than NCD’s. Resource limits at the national level have kept the development of new policies at the local level. It’s possible that a procedure that you need may initially seem as though it is not a Medicare covered service when, in fact, there is a local coverage determination in your jurisdiction that allows the procedure to be covered.

The Ametros team consists of Certified Professional Coders and benefit professionals with over 20 years of Medicare experience. For individuals on our CareGuard platform, we review pre-service requests for compliance and review provider bills to determine both Medicare compliance and injury relatedness. We review both national coverage determinations and local coverage determinations for benefits. More importantly, the team ensures that injured individuals can receive the Medicare covered treatment that is needed for their work-related injury while protecting their future Medicare coverage.

Determining Medicare coverage can be overwhelming and pose questions, but with help from a professional administrator, individuals will be supported in finding Medicare covered items and services for their care needs. On the contrary, in certain scenarios when a medical item or service is not covered by Medicare in their jurisdiction, a professional administrator can help find alternative solutions for them.

Hear from Our Member on Being Supported with Ametros  

To help address Medicare coverage for certain items and services that injured individuals frequently inquire about, we’ve compiled a list below of Medicare covered and non-covered items that may have coverage nuances in certain situations. For certain items, that are not covered by Medicare, we’ve provided alternative solutions that can help individuals receive the care they’re looking for without having to pay out of pocket.

Medicare Covered

  • Aqua Therapy – Aqua Therapy is a covered service when performed as part of a course of physical therapy by a licensed physical therapist
  • Acupuncture – Acupuncture is covered for chronic low back pain
  • Advanced Care Planning – An individual’s physician can help with planning for their care if they become unable to speak for themselves and decide who they would want to speak for them. Individuals can discuss this with their health care provider, and he/she can help them with the necessary forms
  • Chiropractor Services – Chiropractic services for spinal manipulation (only for spinal areas in the back and neck) are covered. Other services, such as xrays, labs, diagnostic studies and massage, are not covered when performed by a Chiropractor
  • Massage - Massages are covered by Medicare when it is performed by a licensed physical therapist as part of an injured individual’s treatment plan
  • Personal Care Attendants - Intermittent skilled nursing care or other skilled services such as in-home physical therapy are all covered services
  • Second Surgical Opinions – Medicare covers second surgical opinions for non-emergency surgeries. Sometimes Medicare may cover a third surgical opinion if requested
  • Transitional Care Management Services – if individuals are returning home from a hospital or skilled nursing facility, their physician can coordinate and manage their care for the first 30 days after their return home. Their provider can work with them, their family, caregivers, and other providers to help with their transition back to living at home. They can get assistance with referrals or arrangements for follow up care or community resources and get help with scheduling appointments and medication management

Medicare Non-Covered & Alternatives Solutions

  • Dental - Dental service providers may work with injured individuals on monthly payment arrangements to make the cost of non-covered services more manageable
  • Out of Country - Medicare does not cover services outside of the United States. A professional administrator can work with injured individuals to assist in obtaining cost effective, in network services
  • Botox Injections - Medicare does not cover Botox for cosmetic purposes, however it may be covered to manage migraine pain
  • Lift Chairs - Medicare does not cover furniture but covers the seat lift mechanism. If a temporary solution is needed, injured individuals may be able to rent from a local DME supplier
  • Unclassified - Biofreeze, gloves, hot & cold packs, and shower chairs, are not covered. Injured individuals can often find coupons available for these items to reduce out-of-pocket costs


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1 Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/What-is-a-MAC. CMS.gov. 


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