Why You Need to Question the Insurance Carrier’s Proposed Medicare Set-Aside (MSA)

Why You Need to Question the Insurance Carrier’s Proposed Medicare Set-Aside (MSA)

You have suffered an injury on the job and in an effort to settle the matter your employer’s workers’ compensation insurance carrier will present to you and your attorney their proposed Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA). This document is prepared by a vendor retained by the carrier. Read on and contact our team to learn more about why you should question the insurance carrier’s proposed Medicare set-aside (MSA).

The WCMSA allocates a portion of the workers’ compensation settlement for all future work injury-related medical expenses. This document sets forth the anticipated costs for your future medical expenses and it is submitted to the Centers for Medicare and Medicaid Services (CMS) for approval of that amount. Assuming that CMS approves the amount and the parties settle the matter, this amount is then deposited in your Medicare Set-Aside Account (MSA Account).

The WCMSA is a crucial document in that it is used to determine how much money will be set aside to address your future medical expenses. You may ask yourself, so what? If CMS approves the amount, once it has all been spent, Medicare will cover the costs of my treatment.

The Reason You Should Question Your Insurance Carrier’s Proposed MSA

Hold on – what you may not realize is that while the funds in your MSA Account are used to cover your medical expenses, you will not be responsible for co-pays. The total cost of the medical treatment is paid for out of the account. But when those funds are fully exhausted and Medicare starts paying for your treatment you will be responsible for co-payments and they can become quite costly. So, it is very important that the proposed amount for future medical care be as accurate as possible.

With this in mind, you must consider that it is in the insurance carrier’s best interests that the proposed amount set aside for future medical care be as low as possible, while still being high enough that CMS will approve it. This is not in your best interests, because once the approved amount is used up, you will be responsible for co-pays.

This is why the insurance carrier’s proposed set-aside amount must be viewed with skepticism. The vendor they choose to prepare the document is not independent, they work for the carrier. More than likely they prepare thousands of these proposals a year for the carrier and they know that their primary goal is to propose an amount that is as low as possible.

So, how does the carrier’s vendor underprice the proposed amount for future medical treatment while still being able to secure CMS approval for that proposed amount? They incorporate many methods, such as proposing fewer doctor visits than you may require, failing to include surgeries that you may require in the future and using the lowest prices listed in the drug pricing database even though the price selected does not reflect the actual price that is available to you.

What happens if you don’t question your insurance carrier’s proposed MSA?

It’s also important to note that the MSA only covers treatment that would otherwise be covered by Medicare.   Medicare does not cover all treatment that is normally paid by the workers’ compensation insurance carrier and has frequency limits on other treatment.    Some examples include acupuncture, chiropractic care, attendant care, and medications prescribed off-label.

This is where MSA Meds can provide your attorney with a realistic cost estimate for your future medical care. MSA Meds will review the carrier’s proposed WCMSA and highlight for your attorney where it is underfunded and also provide the cost of non-Medicare covered treatment. Armed with this information, your attorney can then negotiate with the insurance carrier with the knowledge of a more accurate picture of costs you will incur moving forward.

Contact MSA Meds   

MSA Meds mission is to assist your attorney in maximizing the amount set aside to cover your future medical treatment and to assist you in administering those funds so you can focus on what is most important – your health and wellbeing. Contact MSA Meds today.