Injured parties managing Medicare Set-Asides (MSAs) must adhere to certain rules: 

• Use MSA funds exclusively for Medicare-covered treatments related to the injury.
• Maintain funds in a separate, interest-bearing bank account.
• Keep and organize all related bills and receipts.
• Report expenditures to CMS annually or when funds are depleted.

Key Rules for MSA Administration 

Adhering to MSA administration regulations is crucial. Here’s a breakdown of important points to remember: 

• Medicare-Covered Expenses: The primary rule is that MSA funds can only be used for expenses that Medicare covers, directly pertaining to the injury. This helps ensure continued Medicare coverage when MSA funds deplete.

• Dedicated Bank Account: MSA funds should be stored in a separate, interest-bearing account to prevent commingling with other funds and simplify accounting.

• Record Keeping: Maintaining accurate records is essential. This includes: 
  • Copies of all bills and receipts.
  • Detailed reports of every expense funded by the MSA. 

These records must be submitted to the Centers for Medicare and Medicaid Services (CMS) in an annual attestation. 

Reporting and Compliance 

• Annual Reporting to CMS Regular reporting is mandatory to prove that MSA funds are used correctly. Failing to do so could lead to Medicare denial of injury-related treatments. 

• Depletion and Exhaustion Forms In cases where MSA funds are depleted: 
  • File a temporary depletion form for future annuity payments.
  • Submit a permanent exhaustion form if funds are permanently exhausted.

Professional Administration 

CMS highly recommends using professional administrators, like Ametros, to ensure proper management and reporting of MSA accounts. This can mitigate risks related to compliance and ensures government reports are accurate. 

Further Details and Resources 

For comprehensive guidance, refer to CMS' WCMSA Reference Guide and Self Administration Toolkit. These resources offer in-depth information on navigating MSA administration, ensuring compliance, and safeguarding your Medicare benefits.

The injured party can use their Medicare Set-Aside (MSA) funds on Medicare-approved expenses directly related to their injury. Your MSA account can only be used to pay for medical treatment or prescription drugs that are both related to your workers' compensation injury and would be covered by Medicare. This applies even if you're not yet a Medicare beneficiary.

Allowed expenses for MSA funds

All allowed expenses must be primarily for medical care rather than general health or cosmetic purposes and must be related to the injury that necessitated the MSA. Expenses that are usually allowed include:

1. Medical care: Doctor visits, hospital services, surgeries, and lab work.
2. Prescription medications: All medications prescribed by a physician.
3. Durable medical equipment and supplies: Crutches, wheelchairs, blood sugar test kits.
4. Physical therapy and rehabilitation services.
5. Hearing aids and batteries.
6. Dental care: Cleanings, fillings, extractions, dentures, and orthodontia.
7. Vision care: Eye exams, glasses, contact lenses, and laser eye surgery.
8. Mental health services: Therapy, psychiatric care, and addiction treatment.
9. Preventive care: Screenings, annual physicals, and immunizations.
10. Qualified long-term care services.
11. Travel expenses essential for medical care (gas mileage, parking, tolls).

What expenses are not allowed to be paid from an MSA account?

It's important to note that MSA funds cannot be used for any other expenses other than the Medicare-approved items and services connected to the injury. Misuse of funds can lead to penalties or affect future Medicare coverage.

1. Health insurance premiums (with certain exceptions like COBRA, long-term care insurance, or health insurance while receiving unemployment benefits)
2. Cosmetic procedures that aren't medically necessary (such as cosmetic surgery, teeth whitening, etc.)
3. General health products like vitamins, supplements, or toothpaste (unless specifically prescribed for a medical condition)
4. Non-prescription medications (except insulin and some OTC items with a doctor's prescription)
5. Expenses incurred before your MSA was established
6. Gym memberships or fitness programs (unless specifically prescribed by a doctor for a medical condition)
7. Expenses reimbursed by other insurance
8. Funeral expenses
9. International medical treatments (in most cases)

Managing MSA expenses effectively

If you are self-administering your MSA, it’s important to carefully review healthcare provider bills to ensure they are only for items and services that are both related to your workers' compensation claim and covered by Medicare before paying. Proper management of your MSA funds ensures that once your account is appropriately exhausted, Medicare will pay for future treatments.

Managing MSA expenses yourself can be complicated. We’re here to help – with CareGuard, you'll never deal with a medical bill alone, and our experts will file any necessary Medicare Set Aside reporting on your behalf.

Additional Guidance on MSA Accounts

For more detailed information about managing and using MSA funds in accordance with Medicare guidelines, consult the WCMSA Reference Guide.

If you do not properly manage your MSA account, you could severely jeopardize Medicare paying for your future medical care. Consequences include: denial of future bills from Medicare if your funds exhaust and being required to repay your MSA account for expenses that were paid for that are not covered by Medicare. Medicare reserves the right to have reporting for up to the entire settlement amount on medicare covered treatments before Medicare agrees to begin covering injury-related bills.

If the injured party doesn’t properly manage their MSA account, Medicare will deny paying for their injury-related treatment until the reporting is corrected. To do so, the injured party will have to pay back any amount that was used on an improper expense not relating to their injury back into the MSA account.

Mismanaging the MSA account will jeopardize the injured party’s future Medicare benefits; for this reason, it's important to be careful and seek assistance. Medicare "highly recommends" the use of a professional administrator.

If you have a structured settlement and use up all the money in your MSA account before your next annual deposit arrives, your next steps depend on your Medicare status.

Handling an exhausted MSA if you are a current Medicare beneficiary

If you are a Medicare beneficiary, you should send an attestation letter to the Benefits Coordination & Recovery Center (BCRC) stating that your account is temporarily depleted. You can then bill Medicare for any additional expenses related to your workers' compensation injury until your next annual deposit is received.

This creates a situation where you will have alternating primary payers: first yourself through the MSA, then Medicare while your account is depleted, and then yourself again when your account receives its next funding. This alternating payment responsibility can be confusing for healthcare providers. It's important to clearly communicate with them about when they should bill Medicare instead of expecting payment from your MSA account.

If you have MSA funds to pay part of a bill but not all of it, it’s recommended you ask healthcare providers to send the entire bill to Medicare rather than paying it yourself.

Handling an exhausted MSA if you are NOT a Medicare beneficiary

If you are not yet a Medicare beneficiary when your account is temporarily depleted, you will need to use other insurance to pay for workers' compensation injury treatments until your MSA receives its next deposit. If you have no other insurance coverage, you will unfortunately have to pay out of pocket for these treatments until more funds are deposited into your account.

If you are self-administering your MSA, you can find more information about attestation in Self-Administration ToolKit v. 1.7

We’re Here to Help

With CareGuard, you're never deal with a medical bill alone. If you have a Medicare Set-Aside, CareGuard ensures full compliance by handling all necessary reporting to The Centers of Medicare and Medicaid Services (CMS), giving you peace of mind.

CareGuard also simplifies your care-related payments. Just present your CareGuard card at your doctor’s office or pharmacy, and we’ll handle the rest.

Please note: While CareGuard streamlines the billing process, there may be situations where members are responsible for paying a bill directly. In such cases, members can submit the invoice for reimbursement, as outlined in the Member Agreement provided at enrollment.

Learn more about CareGuard

Unused Medicare Set-Aside (MSA) funds remain in the MSA account and are carried over to subsequent years. These funds are reserved to cover medical treatment related to the claimant's workers’ compensation claim which Medicare would otherwise cover.

Carrying Forward Unused MSA Funds

According to the Centers for Medicare & Medicaid Services Self Administration Toolkit, if any funds are left over at the end of a year, they do not vanish. These remaining funds carry over to the next year, allowing usage of both the new annual deposit and the previous year's leftover amount. This continuous rollover ensures that all accumulated funds are used appropriately.

Post-Claimant Death Fund Management

In the event of the claimant's passing, if unused MSA funds remain, CMS may require reimbursement for any outstanding covered medical expenses. Medical providers have up to 12 months from the date of service to bill. Once all obligations to Medicare are cleared, the remaining MSA funds can be disbursed according to state law and the specific settlement agreement, potentially holding the account open for a period post-death.

For more detailed guidance, please refer to the Workers’ Compensation Medicare Set-Aside Reference Guide, v3.1 and the Self Administration Toolkit, v1.3. These resources cover comprehensive information on managing MSA accounts and handling funds responsibly.

When your Medicare Set-Aside (MSA) funds are exhausted, Medicare will begin to pay for covered items related to your injury, provided that you have properly managed and reported your MSA spending to Medicare. Additionally, you must be enrolled as a Medicare beneficiary. If these conditions are met, Medicare covers you just like any other beneficiary, including the applicable co-pays, coinsurance, and deductibles. 

Conditions for Medicare to Step In 

Proper Management of MSA Funds: If your MSA funds are depleted according to Medicare’s guidelines, and you've reported your spending correctly, Medicare will become the primary payer for your future medical expenses related to the injury. 

Requirements to Ensure Coverage 

To qualify for Medicare to cover your injury-related medical expenses after your MSA is exhausted: 

• Enrollment in Medicare: You must be enrolled during an enrollment period.
• Correct Management of MSA Funds: Adhering to Medicare’s rules for managing your MSA is crucial. 

Failure to correctly manage and report your MSA funds may result in a denial of coverage for injury-related care. Incorrect handling might jeopardize your future Medicare benefits. 

Steps if Coverage is Denied 

If your care is denied, you must replenish your MSA account for any unaccounted expenses and correct reporting to Medicare. It may be helpful to consult a professional administrator for assistance in managing your MSA effectively. 

For detailed information about the rules and proper management of your MSA, consider referring to the WCMSA Reference Guide. 

What if I want to self-administer my Medicare Set-Aside?

Injured parties have the option to self-administer their Medicare Set-Aside (MSA). While Medicare does not recommend this approach, it is possible for individuals to manage their own accounts.

Self-Administration Toolkit

For those choosing to self-administer, there is a 31-page Self Administration Toolkit available. It is essential for the injured party to become acquainted with this toolkit to effectively manage their MSA funds.

Importance of Legal Familiarity

Besides the toolkit, it’s crucial for the individual to understand the WCMSA Reference Guide and the Federal Medicare Secondary Payer Act (42 U.S.C. §1395 et seq), which are subject to periodic amendments.

Using Ametros’ Amethyst Service for Self-Administration

Ametros provides a service known as Amethyst, which aids individuals in self-administering their MSA with added support. This service links directly to the injured party’s personal bank account, offering the convenience and control of their settlement funds. With the Amethyst card, functioning similarly to a traditional insurance card, individuals can easily manage their medical funds while benefiting from support and savings — akin to what is offered by CareGuard.

Why Consider Professional Administration?

Many parties opt for professional administration to avoid potential pitfalls and to ensure compliance with Medicare guidelines. For further reading and detailed information about self-administration, you can explore additional resources in the WCMSA Reference Guide and other relevant documents.

For comprehensive guidance and the most up-to-date information, it is recommended to review the latest WCMSA Reference Guide and consult with professionals who can provide personalized advice based on current regulations.

Why is professional administration recommended for an Medicare Set-Aside?

What happens to unused Medicare Set-Aside funds?

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Many Medicare Set-Asides (MSAs) are not reviewed or approved by Medicare because they fall below the thresholds for review. In some cases, even substantial MSAs are not submitted for review by the parties involved in the settlement. Importantly, the process of review and approval by Medicare is entirely voluntary. If the amount set-aside is reasonable and deemed adequate by Medicare, and accurate post-settlement reporting is conducted, Medicare will assume the role of the primary payer once the MSA funds are depleted.

Understanding Medicare Set-Aside Review

Why Some MSAs Are Not Reviewed: Some MSAs don't undergo Medicare's review due to their falling under the specified minimum necessary thresholds. This happens often in cases where smaller sums are expected to cover the entirety of future medical costs.

Voluntary Submission for Approval: Submission of an MSA for Medicare's review is voluntary. It depends on the parties involved in the settlement to decide whether to seek approval for larger MSAs.

When Does Medicare Become the Primary Payer?

Medicare steps in as the primary payer once the MSA funds are exhausted, provided that the Set-Aside was considered reasonable. It's crucial that all post-settlement reporting connected to the MSA should be detailed and precise to ensure there are no issues with Medicare taking over.

Final Details: Understanding the Process

For more detailed information on Medicare Set-Asides, including guidance and considerations, you might refer to authoritative resources such as the WCMSA Reference Guide. This guide details the processes involved and various scenarios related to MSAs.

Purpose and Coverage

While both MCPs and MSAs involve funding for medical expenses, their purposes differ. An MSA is specifically for Medicare-covered services related to a particular injury. In contrast, an MCP is assigned for medical expenses that Medicare does not cover or that are unrelated to the injury.

Flexibility and Management

MCPs, sometimes known as "Non-Qualified" medical expense accounts or Medical Custodial Accounts when managed by professional administrators, offer more flexibility. They do not have Medicare reporting requirements and can cover a wider range of treatments.

Post-Exhaustion Payment

One key distinction is what happens when funds run out. With an MCP, if funds are depleted, Medicare does not automatically step in to cover expenses, unlike with an MSA.

Final Thoughts on Medical Cost Projections

For those settling claims that require prediction of future medical expenses beyond standard Medicare coverage, considering a Medical Cost Projection can be beneficial. MCP accounts are advantageous for their flexibility and ability to manage non-Medicare eligible medical costs. For more complex details, refer to specialized legal or financial professionals.

For further understanding, it may be helpful to consult additional resources or legal professionals regarding MCP specifics and implications in settlement agreements.

A Medicare Set-Aside (MSA) is not mandatory but is a proactive measure to demonstrate that Medicare's interests were considered during a settlement. An MSA allocation report outlines items related to the injury that Medicare would cover. Submission to Medicare for approval is voluntary to ensure the allocated amount is accurate.

Understanding Medicare's Interests in Settlements

Under Section XVIII of the Social Security Act, interests of Medicare must be considered in injury settlements. Though not required, some parties might opt to create an MSA report detailing costs that Medicare would cover.

Voluntary Review by Medicare

Medicare offers to review these allocation reports when the injured party is, or soon will be, Medicare-eligible, and the amounts are significant. While Medicare review is voluntary, adhering to the following thresholds can make it beneficial:

1. The claimant is a Medicare beneficiary, and the settlement exceeds $25,000.
2. The claimant expects Medicare enrollment within 30 months from settlement and expects future medical expenses and disability/lost wages settlement to exceed $250,000.

Who Is Eligible for Medicare?

Individuals are eligible for Medicare after age 65 or if under 65 and receiving Social Security Disability Insurance (SSDI), with exceptions in certain cases.

For detailed insights about MSA processes and requirements, refer to guidelines or consult professionals experienced with the Social Security Act and related Medicare stipulations.

There is no specific statute or regulation that formally mandates a Liability Medicare Set-Aside (LMSA). However, failing to consider Medicare's future interests can have significant consequences.

Involving a Medicare Set Aside (MSA) in a liability case requires careful consideration of Medicare's interests. The Centers for Medicare and Medicaid Services (CMS) have maintained that Medicare’s interests should be taken into account when resolving liability claims. 

Related reading:

• Understanding Medicare Set-Asides for Personal Injury Cases
• What Is a Medicare Set-Aside?
• Liability Settlement Services
  
  

Steps to involve a Liability Medicare Set-Aside (LMSA)

Unlike Workers' Compensation MSAs, LMSAs lack formal CMS review thresholds. No specific regulations mandate when liability cases require Medicare Set-Asides. Settlement parties must evaluate each case individually to determine LMSA necessity.

Involving a Medicare Set-Aside in liability cases requires systematic assessment and planning. The process protects Medicare's interests while facilitating settlement negotiations.

1. Assess the need for an MSA

Several factors trigger MSA consideration in liability cases. Settlement value represents the primary indicator for potential MSA involvement.

Common triggers include:

• Total settlement values exceeding $25,000
• Significant allocation for future medical expenses
• Claimant's current or future Medicare eligibility
• Ongoing medical treatment requirements
• Injury severity suggesting long-term care needs

The assessment requires case-by-case analysis. Consider the potential cost-shift to Medicare and plaintiff's Medicare status.

2. Obtain a professional MSA report

Professional MSA reports provide detailed calculations for future medical costs. These reports require comprehensive medical information and treatment projections.

Essential information includes:

• Complete medical records from injury date
• Current treatment plans and provider recommendations
• Diagnostic imaging and test results
• Medication lists and prescribing patterns
• Life expectancy considerations

The calculation methodology considers injury-specific treatment needs. Professional evaluators project future Medicare-covered expenses based on established medical protocols.

3. Integrate MSA reports into settlement negotiations

MSA reports influence settlement values and negotiation strategies. The projected amount affects both parties' settlement positions.

Settlement agreements should address Medicare's future interests explicitly. Release language must account for MSA obligations and fund allocation requirements.

The MSA amount typically becomes part of the overall settlement structure. Parties negotiate how MSA costs impact the total settlement value.

Historical Context and Guidance

• Important Memos and Calls: Since the 2001 “Patel Memo,” there have been varying interpretations regarding MSAs in liability cases. Key documents, like the May 25, 2011 “Stalcup” memo, emphasize considering Medicare’s interests.
• Rulemaking and Reviews: CMS initiated a rulemaking process in 2012, though it paused in 2014. Subsequent updates have been anchored around the Workers' Compensation Review Contractor’s (WCRC) ability to review Liability Medicare Set Asides (LMSAs).
• Future Regulations: CMS issued a notice in 2018 for anticipated rulemaking on future medicals. Speculation suggests this could address LMSAs, but proposed rule issuance has been extended several times, most recently to August 2020. 

Considerations in Liability Cases

In the absence of firm regulations, liability cases need a tailored approach: 

• Case-by-Case Analysis: Analyze the potential cost-shift to Medicare and the plaintiff's Medicare status.
• Risk-Management Philosophy: The payer’s risk management strategies and the parties' philosophies play a crucial role in decision-making. 

Funding mechanisms for Medicare Set Asides

Two primary funding approaches exist for MSA implementation. Each method offers distinct advantages and administrative requirements.

1. Lump Sum Funding

• The entire MSA amount is deposited into the account at the time of settlement.
• Provides immediate access to all funds.
• Requires careful management to ensure the funds last for the claimant’s lifetime medical needs.

2. Structured Settlement (Annuity Funding)

• An initial deposit (often called “seed money”) is made to establish the account.
• Followed by periodic payments—typically annual—over a set number of years.
• Reduces the upfront cost of settlement and helps ensure funds are replenished over time.

Both methods must comply with CMS guidelines, and funds can only be used for Medicare-covered, injury-related expenses. Regardless of the funding method, professional administration is strongly recommended to ensure compliance and proper reporting to Medicare.

Related reading: Professional Administration and Your Health- Ametros

Documentation requirements

Thorough documentation supports MSA decisions and compliance efforts. Records demonstrate consideration of Medicare's interests regardless of final approach.

Key documentation includes:

• MSA assessment reports and calculations
• Medical evaluations supporting treatment projections
• Settlement negotiation records addressing Medicare interests
• Attorney opinions on MSA necessity
• CMS submission materials when applicable

Documentation protects all parties from future Medicare recovery actions. Proper records demonstrate good faith compliance efforts.

Post-settlement administration options

MSA funds require ongoing management after settlement completion. Two primary administration approaches serve different client needs.

Self-administration benefits:

• Direct control over fund management
• Potentially lower administrative costs
• Flexibility in provider selection and treatment timing

Professional administration benefits:

• Expert compliance oversight
• Detailed record-keeping and reporting
• Protection from administrative errors
• Medicare communication handling

Professional administrators manage fund disbursements and Medicare reporting requirements. They provide expertise in complex compliance situations.

Settlement thresholds for consideration

Settlement value guidelines help determine when MSA consideration becomes necessary. These thresholds derive from Workers' Compensation practices and industry standards.

Related reading:

• When is a Medicare Set-Aside necessary?
• FAQs: Medicare Set-Asides

Common threshold guidelines

Industry practice references specific dollar amounts for MSA consideration. These amounts trigger initial assessment of Medicare Set-Aside necessity.

Typical thresholds include:

• $25,000 total settlement value
• $5,000 allocated for future medical expenses
• Combination of settlement size and medical allocation

These thresholds represent industry guidelines, not formal regulatory requirements. Each case requires individual assessment beyond threshold considerations.

Medicare eligibility considerations

Current and future Medicare eligibility significantly impacts MSA necessity. Settlement timing relative to Medicare enrollment affects compliance requirements.

Key eligibility factors:

• Current Medicare beneficiary status
• Age proximity to Medicare eligibility
• Disability-based Medicare qualification
• End-stage renal disease considerations

Medicare eligibility within 30 months of settlement typically triggers MSA consideration. Earlier eligibility dates increase compliance obligations.

Regulatory context

These thresholds lack formal CMS endorsement for liability cases. They represent industry best practices adapted from Workers' Compensation guidance.

CMS has not established specific LMSA submission requirements. The thresholds provide practical guidance for risk management decisions.

The importance of compliance with MSA requirements

Addressing Medicare interests protects all parties from future complications. Proper MSA consideration prevents costly recovery actions and legal challenges.

Protection strategies include:

• Thorough MSA assessment and documentation
• Professional evaluation of Medicare interests
• Appropriate settlement structure addressing future medical needs
• Compliance monitoring throughout settlement process

Risk management approaches vary based on case facts and party philosophies. Professional guidance helps navigate complex compliance requirements.

Professional administration for LMSAs

Professional administration offers expert oversight for LMSA fund management. Third-party administrators handle compliance requirements and Medicare reporting obligations. This service protects injured parties from administrative errors and regulatory complications.

Key service advantages:

• Expert compliance monitoring and reporting
• Detailed record-keeping for all transactions
• Medicare communication and correspondence handling
• Protection from administrative mistakes and oversights

Professional administration ensures proper fund utilization according to Medicare guidelines. Administrators verify that expenses qualify for MSA reimbursement before payment.

Administrative services and oversight

LMSA administrators handle day-to-day fund management responsibilities. They process reimbursement requests and maintain comprehensive documentation. Professional oversight protects against improper fund usage and compliance violations.

Core administrative functions:

• Review and approve medical expense reimbursements
• Maintain detailed transaction records and reporting
• Coordinate with Medicare regarding fund status
• Provide annual account statements and compliance reports

Administrators ensure MSA funds are used only for injury-related medical expenses. They verify provider credentials and treatment necessity before approving payments.

Risks of non-compliance with Medicare requirements

Failing to address Medicare's future interests creates significant legal and financial risks. All settlement parties face potential consequences for inadequate MSA consideration.

Related reading:

• What if my Medicare Set-Aside was never reviewed and approved by Medicare?
• Medicare is a Secondary Payer: Lessons Learned with Medicare Set-Aside Accounts in Workers' Compensation and How They Might Apply to Liability Settlements

Medicare recovery actions

Medicare can pursue recovery from multiple settlement parties. Recovery actions target funds that should have addressed future medical expenses.

Potential targets include:

• Injured plaintiffs who received settlement funds
• Insurance companies making settlement payments
• Attorneys facilitating settlement agreements
• Other parties involved in settlement process

Recovery actions can occur years after settlement completion. Medicare's subrogation rights continue despite settlement finalization.

Double damages provision

The Medicare Secondary Payer Act includes double damages penalties. This provision significantly increases financial exposure for non-compliance.

Double damages apply to amounts Medicare pays for injury-related care. The penalty doubles the original Medicare expenditure amount.

Impact on Medicare benefits

Improper MSA handling can affect future Medicare coverage. Beneficiaries may face coverage denials for injury-related treatment.

Medicare may refuse payment for services it believes settlement funds should cover. This creates personal financial liability for the injured party.

Looking Ahead

As the industry awaits final CMS rulemaking, stakeholders should remain vigilant about updates in the legislation affecting LMSAs. 

For more detailed guidance on Medicare Set Asides, review the WCMSA Reference Guide. 

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The necessity of a Medicare Set-Aside (MSA) arises when ensuring that Medicare's interests are protected in workers’ compensation settlements resolving medicals. While there are no strict legal mandates to prepare or submit an MSA to the Centers for Medicare & Medicaid Services (CMS), it is the sanctioned method to safeguard Medicare's interests.

What is a Medicare Set Aside?

An MSA allocates funds from a workers' compensation settlement specifically for future medical expenses that Medicare covers, related to the work injury. This ensures compliance with the Medicare Secondary Payer (MSP) laws, which are in place to prevent unnecessary cost-shifts to Medicare.

When Does CMS Review an MSA?

CMS will conduct a voluntary review of proposed Workers' Compensation Medicare Set Asides (WCMSAs) to ensure that the allocated amount sufficiently covers future Medicare-covered medical expenses from the settlement.

Conditions for CMS Review:

• Current Medicare Beneficiary: If the claimant is a Medicare beneficiary and the total settlement amount exceeds $25,000.
• Future Medicare Enrollment: If the claimant is expected to enroll in Medicare within 30 months and the settlement total, covering future medical expenses and disability, is anticipated to exceed $250,000.

The Importance of CMS Approval

Opting for CMS review and approval of a proposed WCMSA offers a level of assurance and finality to Medicare beneficiaries and workers’ compensation entities. Without this approval, Medicare may deny related medical claims or seek recovery of payments up to the total settlement amount if related medical expenses are covered by the settlement but paid by Medicare.

For a more comprehensive understanding and specific guidance on when and how an MSA should be prepared, refer to the Workers’ Compensation Medicare Set-Aside Reference Guide, v3.1.