You’re finally close to settling your workers’ compensation case in Naperville. Then you hear a new term that raises more questions than answers: “Medicare Set Aside” (MSA).
Many injured workers dealing with MSA workers’ comp issues worry about how this step affects their settlement, their future medical care, and their Medicare eligibility. Understanding how this process works can help you make informed decisions before finalizing your settlement.
Contact us today at 331-INJURED to discuss your case and learn how we can help you.
What Is MSA in Workers’ Comp?
Medicare Set Aside (MSA) is an arrangement that reserves a portion of your workers’ compensation settlement to pay for future medical care related to your work injury. If you end up needing more treatment for your injury further down the line, you must first use the funds in your MSA before Medicare will cover additional care costs.
The system stems from the Medicare Secondary Payer (MSP) Act, which aims to prevent Medicare from paying for treatment that workers’ compensation insurance should cover.
An MSA helps:
- Protect your future Medicare coverage;
- Cover anticipated medical expenses related to your injury, and
- Reduce disputes after your settlement.
Failing to properly set up an MSA can affect your settlement and access to medical care after your case closes. If future medical expenses are not properly addressed, Medicare may refuse to pay for treatment later.
When Is a Medicare Set Aside in a Workers’ Comp Settlement?
An MSA in workers’ comp cases is often recommended when your settlement includes money for future medical care, and Medicare may be responsible for that care down the line.
This often applies if:
- You are currently enrolled in Medicare;
- You are likely to become eligible for Medicare within the next 30 months;
- Your settlement includes compensation for future medical expenses; or
- Your injury requires ongoing treatment after your case resolves.
In these situations, part of your settlement may need to be set aside to cover future medical costs before Medicare will begin paying.
Understanding whether you need an MSA in your case can help you protect your benefits. It can also help you avoid delays and move you through the settlement process more smoothly.
MSA Workers’ Comp Settlement: How It Affects Your Case
An MSA changes how part of your workers’ comp settlement gets handled. A portion of the funds must be used only for future medical care related to your injury.
A settlement involving an MSA may include:
- Lump-sum funding. You receive the MSA amount upfront.
- Structured settlement annuity. Payments for care are made over time.
- Separate account use. Funds must only cover injury-related treatment.
An MSA workers’ comp settlement adds structure to your case while planning for future medical needs.
What Are Conditional Payments?
Conditional payments are medical bills that Medicare may have already paid for your injury-related treatment before your workers’ compensation case settles.
Medicare makes these payments on a temporary basis, with the expectation that it will be reimbursed once your case resolves. Because of this, you may need to repay Medicare for any injury-related care it covered.
Before finalizing your settlement, you should:
- Identify any conditional payments. Medicare may have paid for doctor visits, hospital care, or prescriptions related to your injury.
- Confirm the correct reimbursement amount. You need to verify how much Medicare is claiming.
- Resolve the balance. These payments must be repaid as part of your settlement process.
Addressing conditional payments early can help prevent delays and avoid complications when closing your case. An attorney can also help review your Medicare claims, confirm the correct amount, and work to resolve any issues before finalizing your settlement.
What Is the CMS Submission and Approval Process?
In some cases, your MSA may go through the Centers for Medicare & Medicaid Services (CMS) submission and approval process, which allows CMS to confirm that the set-aside amount properly accounts for your future medical care.
Here is how the process typically works:
- Preparation of the allocation report. A professional estimates future medical costs.
- Submission to CMS. The report is sent for review when required.
- CMS review. The agency evaluates whether the amount is appropriate.
- Approval or revision. CMS approves or requests changes.
Not all cases go through the CMS review process, and whether submission is appropriate depends on factors like Medicare status and the size of the settlement. Also, while CMS reviews the MSA, the Illinois Workers’ Compensation Commission (IWCC) may still handle other parts of your claim. The IWCC may resolve disputes or approve the final settlement.
Talk to Marker Law About Your Workers’ Compensation Settlement
The MSA workers’ comp process can feel overwhelming, especially when your settlement and future care are at stake. If you are approaching settlement and have questions about an MSA, Marker Law can help.
Attorney Jason Marker brings more than 25 years of experience helping injured workers in Naperville and across Chicagoland. His background working with insurance defense firms provides valuable insight into how claims and settlements are evaluated.
We help clients understand Medicare Set Aside requirements and how they fit into the larger workers’ compensation process. At Marker Law, we guide you through each stage of the process and take action to protect your interests every step of the way.
If you need guidance on an MSA workers’ comp settlement issue, we can help you make informed decisions about your case and your future care.
Contact our office today to better understand your options.
FAQs
What Is an MSA in Workers’ Compensation?
A Medicare Set-Aside (MSA) is a portion of a workers’ compensation settlement set aside to pay for future medical care related to your injury. It helps protect Medicare’s interests and your future coverage.
How Does the CMS MSA Approval Process Work?
The Centers for Medicare & Medicaid Services (CMS) process starts with preparing an MSA allocation report. The report estimates your future medical costs. If your case meets certain requirements, that report is submitted to CMS for review. CMS then evaluates the proposed amount, and either approves it or requests changes before your settlement can proceed.
Who Qualifies for a Workers’ Compensation Medicare Set Aside?
You may need a Medicare Set Aside if you already receive Medicare or are likely to qualify soon, and your injury requires ongoing medical care. This often applies to workers who are age 65 or older, receiving Social Security Disability benefits, or expected to become eligible for Medicare within the next 30 months.
Official Legal and Other Sources
To ensure the accuracy and clarity of this page, we referenced official legal and other resources during the content development process:
- Centers for Medicare & Medicaid Services, Workers’ Compensation Medicare Set-Aside Arrangements.
- Medicare Secondary Payer Act, 42 U.S.C. § 1395y(b)(2)(A) – Exclusions from coverage and Medicare as secondary payer.
- Centers for Medicare & Medicaid Services, WMCSA Submission Process.
- Illinois Workers’ Compensation Commission.