What to Know About Workers’ Compensation & Medicare Set-Asides

The insurance carrier has finally returned your calls and wants to settle your client’s workers’ compensation case. Great news, but make sure the news is actually great. Is your client getting the best possible settlement or is money being left on the table? Read on and contact our team to learn more about worker’s compensation and a Medicare set-aside.

What is a Medicare Set-Aside Agreement?

But first, a little background. The Medicare Set-Aside Agreement (MSA) is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the work injury that Medicare would have otherwise paid. The purpose of the MSA is to protect the Medicare Trust Fund to ensure that Medicare does not pay for certain medical treatments when other coverage should apply. So, remember the primary purpose of the MSA is to protect Medicare.

Reviewing a Medicare Set-Aside Proposal

You must carefully review the MSA Proposal to ensure that is a fair projection of your client’s future medical needs.   MSAs often rely on arbitrary treatment caps and underprice medications and services.   MSAs also do not include non-Medicare covered medical expenses.  This can result in a significant cost difference between the amount of funds CMS is willing to accept to protect Medicare’s interests and the amount of money necessary for your client to receive the medical treatment they need.

So how best do you protect your client from a possible underfunded MSA? Knowledge! And knowledge is power. But knowledge of what? The costs associated with your client’s medical treatment, and that is where MSA Meds can help.

Not only can MSA Meds administer your client’s MSA account in order to ensure compliance with Medicare regulations, we can help you ensure that your client gets a settlement that will actually address their future medical expenses.

Typically, as part of the settlement, the insurance carrier will prepare a proposed MSA allocation. As part of this proposed allocation, they will include the costs of future medical services and medications. It is important to always remember that the carrier has a financial interest in keeping the amount of the MSA as low as possible.  And the Vendor preparing the MSA for the carrier has a financial interest in receiving future business from the carrier.

You must therefore review the proposed allocation with a critical eye. The carrier may very well propose less treatment than your client actually requires – suggesting less doctor visits or trying to limit the number of physical therapy appointments, but these tactics can be readily noticed. However, the more likely route the carrier will take is with regard to the cost of the medication your client is taking for their injuries.

What may not be readily known is that when it comes to the manufacturing of drugs there are many companies that actually make the generic versions of medications and with that comes a multitude of prices for the medications. The issue though is at what price is the medication actually available to your client. Carriers will very often select the generic of the drug listed at the cheapest price on the drug price index. This amount will then form a basis for the proposed amount of the MSA. However, very often the medication will not be available to the general public at that price and thus it does not reflect a real-world estimate of your client’s future medical costs.

MSA Meds can provide you with the cost of your client’s medication at prices that are actually available. This can mean the difference between thousands of dollars your client will not receive to which they would be entitled.

Co-payments for Medical Treatment & Medications

Now let us circle back for a moment. Perhaps you are thinking, well if CMS approves the proposed MSA then Medicare should not deny payments once the MSA funds are exhausted on the basis that the MSA was underfunded. Well, that may very well be true, but your client will not know that for sure until and unless there is a problem at some point in the future. But one issue that does loom for the client is co-payments for medical treatment and medications.

Co-payments are the bane of modern health care coverage. Let us assume that CMS approved the MSA amount but now those funds are exhausted and Medicare starts paying for your client’s treatment. But now your client is going to have to start paying co-pays for their treatment and medication when they did not have to while the MSA funds were being used. These co-pays can be as high as 30 percent and may even increase over time. And while ultimately the MSA funds may be exhausted the more money you can secure for your client’s MSA, the longer it will be until those funds are depleted.

Contact MSA Meds

MSA Meds seeks to level the playing filed for injured workers and their attorneys. Allow us to review the proposed MSA from the carrier and we will highlight for you and your client areas where the MSA is possibly underfunded. Remember, knowledge is power and MSA Meds is here to provide you and your client with that knowledge. Contact MSA Meds today.