A Medicare set-aside is an account created during the settlement of a Workers' Compensation claim by agreement to allocate funds for future medical or prescription expenses related to the claim. This set-aside is created to protect Medicare's interests and rights when the individual who made the claim has Medicare coverage.
Medicare has a financial interest in any payments it makes for illnesses or injuries that are covered by Workers' Compensation, according to 42 U.S.C. sec. 1395Y. In fact, any payment that Medicare makes for such injuries or illnesses while a Workers' Compensation claim is pending must be repaid when the claim is settled. The law requires that individuals and entities involved in a Workers' Compensation claim, including attorneys and insurance companies, continue to protect Medicare's interests even after the Workers' Compensation claim is settled.
The Workers' Compensation Medicare Set-Aside is the method Medicare recommends to protect its interests. The appropriate amount of funds to be placed in a WCMSA must be determined on a case-by-case basis. The funds that are in the WCMSA may be used for any medical expenses related to the Workers' Compensation claim. Those funds must not be used for any other purpose.
Medicare does not pay for any medical expenses related to the Workers' Compensation claim until the funds in the WCMSA are exhausted. The individual may need to prove that the funds were used appropriately. Therefore, Medicare recommends that the individual keep records and receipts related to the expenditure of the funds.