How can a workers’ comp settlement affect Medicare coverage?

Medicare recipients injured in the workplace typically qualify for workers’ compensation benefits. However, before Medicare pays for future treatment, recipients must use at least a portion of these settlements from private insurers.

When this occurs, it’s usually advisable to submit a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA), which protects Medicare’s interests while ensuring coverage of the recipient’s future medical expenses.

A WCMSA is a financial agreement that sets part of your settlement aside for future medical expenses related to your work-related injury, illness or disease.

The Centers for Medicare & Medicaid Services (CMS) determines eligibility, and the WCMSA amount varies by case. Filing the agreement involves five steps.

Submission

You can submit your agreement proposal through:

• The WCMSA online portal
• Paper documents or a CD sent by mail

Medicare officials recommend using the online portal for efficiency. Submissions are recorded in a national, centralized database and forwarded digitally to the agency’s Workers’ Compensation Review Contractor.

Submission acknowledgement

Once you’ve successfully sent the proposal, you should receive:

• Immediate confirmation on the online portal
• An acknowledgment letter by mail

If you don’t receive an acknowledgment letter, contact the Benefits Coordination & Recovery Center.

Review and decision process

The review contractor then decides after:

• Reviewing proposed medical and prescription drug costs
• Evaluating whether the proposed amount is adequate to protect Medicare’s interests
• Obtaining missing or incomplete information related to the case

After the contractor completes the review, they send the recommended value and rationale to the assigned regional office.

Regional office determination

The regional office will then inform you of its determination by sending one of the following by email or mail:

• Approval letter
• Denial letter stating the reason for denial
• Closeout letter explaining why your case was closed

You can visit the CMS website to find out how to reach the regional office assigned to your case.

Request for re-review

You may be eligible for a re-review if your case qualifies. You can submit a re-review request via:

• The online portal
• A written request sent to the WCMSA address

While not mandatory, getting a WCMSA to secure future medical coverage for your workplace injury is advisable. It holds your employer accountable and prevents Medicare non-compliance and any penalties.

Consulting an experienced workers’ compensation lawyer from the outset of your injury can help you meet all legal requirements and make sure you receive a recommended value that can protect your future Medicare coverage.