When is it advisable to obtain a Medicare Set-Aside Arrangement?

When should a Medicare Set-Aside be considered?

At present, if a client has a workers’ compensation claim that is settled either on its own or in conjunction with a third-party claim, it may be appropriate to consider a Medicare Set-Aside in order to protect their future eligibility for Medicare benefits. An MSA should be considered if the claimant is eligible for Medicare or if there is a reasonable expectation that they will become eligible within the next 30 months after the settlement. A Medicare set aside allows the claimant to set aside a portion of the settlement funds specifically for Medicare-covered expenses. These funds are then kept in a separate account. Once the set aside account is properly exhausted, the claimant can receive full Medicare coverage without Medicare considering the remaining settlement funds for their care. Currently, the Centers for Medicare & Medicaid Services (CMS) offers a voluntary review of a Workers’ Compensation MSA (WCMSA) for settlements exceeding $25,000 involving Medicare beneficiaries. CMS is also willing to review any workers compensation settlement if there is a “reasonable expectation” of Medicare enrollment within 30 months of settlement and the total settlement amount over the course of the agreement exceeds $250,000. Failing to meet CMS’ internal workload review thresholds does not ensure compliance with the MSP regulations.

(Test 1) If the injured party is presently enrolled in Medicare AND is anticipated to need post settlement injury-related medical treatment that is covered by Medicare.
? OR ?
(Test 2) If the injured party can reasonably expect to qualify for Medicare within the next 30 months AND is expected to need post settlement injury-related medical treatment that is covered by Medicare.