Workers’ Compensation Medicare Set Aside Arrangements
A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease. These funds must be depleted before Medicare will pay for treatment related to the workers’ compensation injury, illness, or disease.
All parties in a workers’ compensation case have significant responsibilities under the Medicare Secondary Payer (MSP) laws to protect Medicare’s interests when resolving cases that include future medical expenses. The recommended method to protect Medicare’s interests is a WCMSA.
The amount of the WCMSA is determined on a case-by-case basis. Please review the Determining if a WCMSA is Reasonable document to assist you with your WCMSA submission. This document is available in the Downloads section at the bottom of this page.
Additional information for attorneys, Medicare beneficiaries, claimants, insurance carriers, representative payees, and WCMSA vendors can be found in the WCMSA Reference Guide. This Reference Guide is available in the Downloads section found at the bottom of this page.
Please click the sign-up link found in the Related Links section below to subscribe to WCMSA Web page updates. These announcements will also be posted to the WCMSA What’s New page.
When to submit a WCMSA for CMS Review
While there are no statutory or regulatory provisions requiring that a WCMSA proposal be submitted to CMS for review, submission of a WCMSA proposal is a recommended process. More information on this process can be found on the WCMSA Submissions page.
If you choose to submit a WCMSA for review, CMS requests that you comply with its established policies and procedures. CMS will only review new WCMSA proposals that meet the following criteria:
- The claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or
- The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00
For more information on Review Thresholds, please see the WCMSA Reference Guide and the May 11, 2011 Memorandum, available in the Downloads section found at the bottom of this page.
If you decide to submit a WCMSA for review, it can be submitted electronically through the WCMSA Portal (WCMSAP) or by paper/CD through the mail. The portal submission is the recommended approach for submitting a WCMSA as it is significantly more efficient than sending this information via the mail. For more information about this application, please see the WCMSAP page.
- Page last Modified: 03/19/2018 9:42 AM
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