A Medicare Set-Aside (MSA) is an account that is created in the settlement of an individual’s workers compensation claim that is used to pay for future medical expenses that are:

• Attributed to an individual’s work-related injury; and
• Would otherwise be payable by Medicare.

When a MSA is Required

When settling a workers’ compensation claim, a MSA is necessary if the future medical Required aspect of the claim is being settled and one (1) of the following exists:

• The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; or
• The settlement amount exceeds $250,000 and the injured worker can reasonably expect to become a Medicare beneficiary within thirty (30) months of the settlement.

Medicare Benefit Eligibility Requirement

An individual is eligible to receive Medicare benefits for certain medical and hospital expenses if they meet one of the following criteria:

• Are 65 years of age or older;
• Have been receiving Social Security Disability benefits for at least twenty-four (24) months; or
• Are suffering from end-stage renal disease.

Determining the Amount of a MSA

The MSA amount is formulated by consideration and analysis of the following:

• Date of injury and nature of injury
• Rated age of the Claimant and life expectancy
• Review of medical payment history
• Medical diagnosis and prognosis
• Medicare coverage limitations
• Workers’ compensation fee schedules
• Future medical needs for treatment of the work injury