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Information On Pennsylvania Workers’ Compensation Settlements and Medicare Set Asides

A Workers’ Compensation Medicare Set Aside is a financial arrangement which allocates a certain portion of a Workers’ Compensation Settlement for future medical care. The Medicare Set Aside funds must be used up before Medicare pays for the work-related injury or illness.

What is the purpose of a Medicare Set Aside? The purpose is to protect Medicare’s interests. Medicare doesn’t want the burden of work-related medical treatment shifted to them. Indeed, Medicare is a secondary payer. The Medicare Set Aside protects Medicare by ensuring that the workers’ compensation insurer is funding payments for future work-related treatment.

The Medicare Set Aside process is done on a case by case basis. While no statute requires a Medicare Set Aside, it is highly recommended in certain situations.

The Center for Medicare and Medicaid Services will only review a Workers’ Compensation Medicare Set Aside proposal if:

A.   Claimant is a medicare beneficiary and the total settlement is over $250,000.00

OR

B.   If Claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date AND the anticipated total settlement for future medical and disability/lost wages over the life or duration of the settlement is expected to be greater than $250,000.00.

Attorneys and injured workers who are involved in Pennsylvania Workers’ Compensation cases should be cautioned that every settlement has to consider Medicare’s interests. Does that mean every case needs a Medicare Set Aside? No, per the above, CMS will only review when certain factors apply. But, to protect yourself, it is recommended that a certain portion of the settlement proceeds be designated as future medical, even if an MSA is not required, in certain cases where 1) claimant is on Medicare already, 2) claimant will soon be on Medicare, 3) the Pennsylvania Work Comp Settlement is large, 4) you reasonably expect some future work-related medical treatment to take place, or 5) a combination of the above applies. In other words, insert language into the Pennsylvania Compromise and Release Agreement that Claimant will set aside X amount of dollars to pay for future work-related treatment.

Do these rules apply to a Pennsylvania Workers’ Compensation Settlement? Yes!

What about an annuity? How does Medicare determine if the value of the annuity meets the $250,000.00 threshold? Medicare determines the value of an annuity based on how much the annuity is expected to pay over the life of the settlement, not on the Present Day Value or cost of funding the annuity.

If I intend on using other insurance and promise not to have Medicare billed, can I reduce the amount of the Medicare Set Aside? No. The regional officers who review the MSAs cannot approve settlements that promise not to bill Medicare.

Can I state in the settlement agreement that the proceeds are only for past medical treatment in order to circumvent CMS review? You won’t need a set aside if you can prove A) the facts of the case demonstrate that you are being compensated for past medical expenses, B) there is no evidence that you are trying to maximize other parts of the settlement to the detriment of Medicare AND C) your treating doctor writes a report concluding that to a reasonable degree of medical certainty you will no longer require any Medicare-covered treatments for the work injury.

The issue of determining whether a formal Medicare Set Aside proposal in a Pennsylvania Workers’ Compensation case is an important one and should not be taken lightly. Reviewing the cms.gov website and memoranda on a regular basis is recommended.

For a free analysis of your Pennsylvania Workers’ Compensation case, call or email Certified Specialist In PA Workers Comp, Michael W. Cardamone at 215-206-9068 or Michael@cardamonelaw.com Free consultations 7 days a week.

Note that nothing on this blog should be construed as legal advice. No attorney-client relationship is formed unless you sign a Fee Agreement with my office. Every case is different and requires an individual analysis. Michael is licensed to practice law in Pennsylvania. Michael is a senior trial attorney, and managing attorney for Krasno Krasno & Onwudinjo’s Blue Bell, PA office. Michael handles PA Work Comp cases across Pennsylvania. MyPhilly WorkersComp is Michael’s personal brand and is trademarked.

Awards & Recognitions

Pennsylvania Workmans Comp Attorney
Philadelphia Workmans Comp Lawyer

Cardamone Law Has Negotiated Some of the Largest Workers’ Comp Settlements in Pennsylvania

$2.2 Million
Spinal Injury
$897,000
Lower Back Injury
$650,000
Lower Back Injury
$550,000
Neck Injury
$425,000
Leg Injury
$375,000
Knee Injury
$325,000
Ankle Injury
& Hundreds More Cases
$2.2 Million
Spinal Injury
$897,000
Lower Back Injury
$650,000
Lower Back Injury
$550,000
Neck Injury
$425,000
Leg Injury
$375,000
Knee Injury
$325,000
Ankle Injury
& Hundreds More Cases

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"[They] did an excellent job in getting me financially compensated in a fairly short amount of time."

"I recently had a work related injury and was receiving Workers' Compensation (medical benefits only). Soon after I was fired, so I contacted Paul Silver at Cardamone Law Firm who did an excellent job in getting me financially compensated in a fairly short amount of time. Paul and his assistant Shirley always responded to any questions I had about the case in a very short amount of time. Thank you for helping me with this difficult case."

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- Allie M.
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Without a doubt YOU are the best!!!

"Without a doubt YOU are the best!!! Every person who is in the horrible position of being injured at work should have someone as kind, compassionate and knowledgeable as you on their side. You never once made me feel like I was one of a hundred other clients. I always knew you had my back! You answered calls and emails at all hours. You fought every fight for me so I only had to worry about getting well. Behind your nice, calm face there’s a pit bull ready to take on any employer or judge. I can never thank you enough."

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"Michael is simply the best! He was there for me from day 1 till the end, and we won the case!! He is always available to help. I had a gazillion questions and he would answer them one by one. He's a great lawyer and I feel lucky to have found him online from reading other outstanding reviews about him. Believe me, they're true!"

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