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Workers Comp Medicare Set Aside Concerns


Workers Comp Medicare Set Aside (WCMSA)

There are a few concerns that I have concerning my last post on Workers Comp Medicare Set Aside. The info from the CMS website is in italics.


Picture Of Physicians Workers Comp Medicare Set Aside Discussion

Payout totals for all annuities to fund the above expenses should be used rather than the cost or present values of any annuities. Also, any previously settled portion of the WC claim must be included in computing the total settlement amount. To determine the total settlement amount when using an annuity, please be advised that Medicare determines the value of the annuity based on how much the annuity is expected to pay over the life of the settlement, not on the Present Day Value (PDV) or cost of funding that annuity.

As a Chartered Financial Consultant, I often deal with annuities. My concern with the above passage is a very small annuity spread over many years can trigger the reporting limit. If an insurance carrier is looking at lifetime meds, one of the most efficient ways to settle claims will be affected.

If an employer/TPA/insurance carrier wants to avoid the reporting limit, the easiest method would be to shop for annuities that show a lower final payout. This could be detrimental to the injured employee over the long term.

Current Medicare Beneficiaries

Picture Of Family Together Workers Comp Medicare Set Aside On Beach

However, CMS wishes to stress that this is a CMS workload review threshold and not a substantive dollar or “safe harbor” threshold. Medicare beneficiaries must still consider Medicare’s interests in all WC cases and ensure that Medicare is secondary to WC in such cases. In other words, if the total settlement amount is $25,000 or less, the parties to the settlement are still required to consider Medicare’s interests. The recommended method to protect Medicare’s interests is to enter into a Medicare Set Aside arrangement to protect Medicare’s interests, even though CMS will not review the proposal.

The concern here is that even a small settlement with a Medicare beneficiary has to contain a set aside agreement. This may likely affect a large number of lower dollar settlements. This will encourage the carriers/TPAs/employers to not settle these files.

Review Thresholds are Subject to Adjustment

Both the beneficiary and non-beneficiary review thresholds are subject to adjustment. The CMS reserves the right to modify or eliminate its review criteria if it determines that Medicare’s interests are not being protected. Claimants, employers, carriers, and their representatives should regularly monitor this website for changes in policies and procedures.

This paragraph is actually what made me decide to write this article. The review thresholds are subject to adjustment. If the CMS decides their interests are not being protected in the overall Workers Comp industry, then they can modify the rules as they see fit.

What happens if, in 20 years, the CMS says that for the last 30 years, their interests have not been protected on ALL claims under $25,000? Are they allowed to retroactively require MSAs to protect their interests?

Picture Of Two Businessman Workers Comp Medicare Set Aside Discussion

If a carrier/TPA/employer has settled a file that does not require CMS approval, but then the rules now require a WCMSA, would the settlement have to be redone?

What if the settlement had already been paid and the file was closed? Would the file have to be reopened and a new settlement agreement completed? 

When all the data is reported to the CMS and the FIO, will the statistics change? My main point for this article is the CMS based their rules on the statistics they had in their possession. As most carriers have not reported their data, were the conclusions drawn by CMS based on accurate data? That worries me.

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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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