Workers' Compensation

What is a Medicare Set Aside Agreement?

Medicare Set-Asides are phenomena that has come into full force in the last several years. In the old days if an injured worker was on Medicare and his workers’ compensation claim was still open it was pretty common for the worker and the insurance company to settle the claim. Medicare got stuck paying for all the future medical treatment. By “Medicare” we mean the taxpayers of America.

Washington, D.C. got wise to this gambit and now requires that a portion of the settlement be “set aside” for future medical treatment. Once that money is used up Medicare will pay for any additional necessary treatment even if the treatment is related to the workers’ compensation claim.

In larger cases, those involving settlements over $250,000.00, a division of the Social Security Administration has to review the Medicare Set-Aside Agreement to ensure that Medicare’s interests are protected. The problem with this is that we are required to ask the government how much money they would like to take from you. All too often the answer is “more.”

From the insurance company’s viewpoint they don’t necessarily care how the settlement is divvied up between you and Medicare. The adjuster has a certain amount of money to spend on a case and that’s it. The problem arises if Medicare wants too much. Without enough left over you may have no interest in settlement.

It’s important that Medicare be given the proper medical records so that a fair and reasonable estimate may be made. This is all quite complex and usually the job is given to independent companies who specialize in drafting Medicare Set-Aside Agreements.