Medicare Set-Asides: To Submit Or Not To Submit

A Medicare Set-Aside (MSA) is a financial agreement that reserves a portion of a workers’ compensation settlement to cover future treatment and prescription costs of an injury, illness, or disease.

MSAs were designed to protect Medicare from paying for post-settlement treatment related to the underlying injury for which the employer/workers’ compensation carrier would remain liable for if the claim was not settled.

Utilized when an injured worker is or will soon be a Medicare beneficiary, MSAs project future injury-related medical costs over the person’s life expectancy.

In January 2022, there was quite the commotion in the workers’ compensation industry when the Centers for Medicare & Medicaid Services (CMS) released an update to the WCMSA Reference Guide (Reference Guide) that included new information as it pertains to Workers’ Compensation Medicare Set-Asides (WCMSAs).

Of significance was the inclusion of Section 4.3, which, for the first time, addressed CMS’ position on non-submit/Evidence-Based Medicare Set-Asides (EBMSAs).