What is a “Medicare Set-Aside” in a Nevada Workers’ Compensation Case?
A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is where part of your Nevada workers’ comp settlement is placed in an account earmarked for your future medical expenses. Only once those funds are used up will then Medicare kick in and pay for your remaining qualified medical treatments.
Do all workers’ comp settlements have WCMSAs?
No. In general, you will only qualify for a Medicare Set-Aside in Nevada if either:
You are currently on Medicare, and your total workers’ compensation settlement amount is greater than $25,000; or
You will be on Medicare within 30 months of the workers’ compensation settlement, and the total settlement amount is greater than $250,000.1
Therefore, WCMSAs usually only apply to injured workers who are at least 62-and-a-half years old and/or who are applying for social security disability benefits.
What are my obligations if have one?
If your workers’ comp insurance settlement includes a WCMSA, then there are many rules and regulations you have to follow. Among these are:
using the WCMSA funds for only approved treatments and medications related directly to your work injury; and
paying no more than the pre-approved Medicare rate for medical services.2
If the WCMSA funds do go toward unqualified expenses or overpriced treatments and medications, then you may have to pay Medicare out-of-pocket for the overages.
How can I access the funds?
If your Nevada workers’ comp settlement includes a WCMSA, the funds will be kept in an interest-bearing account. You may then withdraw money from this account – such as through a debit card – to go towards qualified medical services and treatments.
Depending on your case, your WCMSA will be in the form of a:
lump sum; or
structured settlement paid out over years.3
What do the funds cover?
The funds in your Workers’ Compensation Medicare Set-Aside go toward all your qualified medical expenses related to your work injury. Depending on your case, this can include:
doctor’s office visits
operations and other medical procedures
home health care
radiology, blood tests, etc.
prescription and over-the-counter medications
medical equipment (such as wheelchairs, walkers, etc.)
Does the CMS need to review my WCMSA?
There is no law that requires the Centers for Medicare & Medicaid (CMS) to review and approve your Workers’ Compensation Medicare Set-Aside. However, it is recommended that you submit it to CMS to review anyway.
The most efficient way to submit your WCMSA to CMS is through its online portal.4
What is the purpose of WCMSAs?
The sole purpose of Workers’ Compensation Medicare Set-Asides is to prevent Medicare from paying any more than it has to.
Since your injury was work-related, your primaryinsurer is the workers’ comp insurance company. As the secondary insurer, Medicare will not pay up until the workers’ comp insurer pays out everything it earmarked under the set-aside arrangement.
A former Los Angeles prosecutor, attorney Neil Shouse graduated with honors from UC Berkeley and Harvard Law School (and completed additional graduate studies at MIT). He has been featured on CNN, Good Morning America, Dr Phil, The Today Show and Court TV. Mr Shouse has been recognized by the National Trial Lawyers as one of the Top 100 Criminal and Top 100 Civil Attorneys.