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What is Medicare Set Aside?

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Imagine you’re injured at work or through someone else’s negligence. Workers comp or a personal injury settlement steps in to take care of medical expenses and lost wages related to your injury. But what if your injury can’t be resolved neatly in a few treatments? What if you’re likely to deal with the repercussions of that injury for the rest of your life? Enter Medicare Set Aside. 

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The Best Medicare Set Aside:

How Does Medicare Set Aside Work?

Workers’ comp cases that involve future medical expenses must allocate funds for treatment related to the injury, illness or disease. This is called a Workers’ Compensation Set-Aside Arrangement (WCMSA). According to the Center for Medicare & Medicaid Services (CMS), all parties in a workers’ compensation case are responsible to protect Medicare’s interests. One way to do this is to set aside funds to pay for future medical treatment using a WCMSA. All the funds set aside must be used before Medicare will pay for treatment related to the workers’ comp injury, illness or disease.

The same is true if you’re injured and receive a personal injury settlement. The money must be set aside to use to treat your injury before you use Medicare to continue treatment for the injury. 

Legalities of Medicare Set Aside

In cases of injury, illness or disease that results in a personal injury settlement, Medicare is a second payer of any related medical treatment. That means that Medicare benefits will only pay for medical care related to your injury after settlement funds are depleted. The Medicare Second Payer (MSP) laws protect Medicare’s interests when cases involve future medical needs. Protecting Medicare means more work for you. 

By law, you’re not required to submit a WCMSA for review by CMS. But, if you’ll need medical services for a workplace injury, illness or disease when you get health insurance through Medicare, it’s in your best interest to do so. As found on cms.gov, CMS reviews WCMSA claims when either arises:

  • The claimant is a Medicare beneficiary and the total settlement amount is greater than $25,000
  • 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 or lost wages over the life of the settlement agreement is expected to be greater than $250,000.

How to Get Medicare Set Aside

You’re required as a current or future Medicare beneficiary to protect Medicare’s interests as they relate to future medical expenses. This may seem like an unnecessary cog in the process of your care and well-being. But, protecting Medicare protects you. Without Medicare Set Aside, you could be responsible for paying for future medical treatment related to workers comp or a personal injury settlement. 

A specialized company will evaluate your future medical needs and recommend an amount that should be set aside. Using that information, you submit a WCMSA claim to CMS. CMS reviews your claim and determines if the amount is correct. CMA can increase, decrease or deny the claim.   

Do I Have to Pay for Medicare Set Aside? 

Technically, you don’t pay for Medicare Set Aside. You put the money you received as a result of your injury into an interest-bearing account. And, you must keep detailed records of expenses paid from the account. Importantly:

  • Money in the Medicare Set-Aside account can only be used for approved medical services and costs related to the original injury. Also, note that the expense must be the approved Medicare rate. 
  • You’re responsible for recording and keeping receipts for everything paid for from the account.
  • You must submit a report to CMS detailing expenses for the year. 

You can choose to keep records yourself or hire professional administration services to keep you on track and in compliance.

Best Medicare Set Aside Administrators

Medicare comes in 4 parts: Part A (hospital insurance), Part B (medical insurance), Part D (prescription drug coverage), and Part C, also known as Medicare Advantage, is a mix of Parts A, B and usually Part D. Some of the best companies for Medicare Advantage plans include Kaiser Foundation Health Plan, Aetna, Humana, Cigna and Highmark. 

Medicare Advantage plans aren’t for everyone. Many prefer original Medicare (Parts A & B). You’ll need prescription drug coverage through Medicare Part D plans. And, you may want to consider adding Medicare Supplemental Insurance to help with expenses like copays, coinsurance and deductibles. 

No matter what form of Medicare you choose, you need to carefully track and manage the use of your Medicare Set Aside account. And that can be a complex and daunting task. The following companies can help you make sure you use your Medicare Set Aside account properly, effectively and efficiently. 

1. Best Overall: Medivest

As one of the first companies to professionally administer a Medicare Set Aside agreement, Medivest provides comprehensive and cost-effective professional administration. Medivest uses state-of-the-art software to manage accounts, review bills and conduct fiduciary accounting. (Fiduciary accounting is a comprehensive report of the activity within the Medicare Set Aside.) 

Medivest shoulders the complicated compliance burden so you can focus on your injury. Additionally, Medivest provides a multitude of coordinating services. Those services include:

  • Negotiating claims with providers
  • Arranging delivery and training on medical equipment
  • Coordinating benefits with your other health benefits
  • Helping to arrange disabled access accommodations during travel
  • Assisting with estate planning of account funds

2. Most Affordable: Ametros

Ametros provides full professional administration and self-administration tools for Medicare Set Aside. Reviewing every bill, the Ametros team looks for ways you can save money to make your benefits go further. Its discount networks give you access to savings on provider visits and prescriptions.

As an Ametros member, you get 24/7 access to care advocate support, see any doctor or provider and access to an online portal so you can review your savings. Plus, Ametros’ CareGuard handles all reporting and makes sure you’re compliant with Medicare guidelines. 

3. Best for Integration: Synergy

Synergy understands the complexities of Medicare. It provides single-source service to properly manage your Medicare Set Aside. Synergy’s services include setup of the Medicare Set Aside, medical bill auditing, interface with medical providers, negotiation of bills, payment of Medicare Set Aside-related expenses and reporting.

It’s also able to analyze your future medical projections and your Medicare Set Aside to make sure you’re getting what you need. Synergy also provides valuable insight before you settle on the amount of your Medicare Set Aside through future medical projections, analysis, case consultation and evaluation.   

4. Best for Service: Medval

Medval takes care of the difficult details of a Medicare Set Aside to save you time, confusion and frustration. Established in 2003, Medval offers you fully integrated service to make sure that you comply with Medicare rules and regulations. They tout attentive administration to ensure your Medicare Set Aside is handled efficiently and appropriately.

Its full-service administration services include bill review and payment, rate negotiation, prescription drug savings, cost containment and account reporting. Additionally, if you’re having problems getting CMS approval, Medval claims that it’s one of the most successful firms to get a decision in favor of its clients.  

5. Best for Cost Containment: Rising

Rising boasts mastery in Medicare compliance with sound financial management and medical cost containment. Its administration services start with setting up a Medicare Set Aside custodial account. From there, Rising determines injury-related charges, makes sure pricing is in line with Medicare, negotiates with providers, provides pharmacy discounts and home delivery options, and disburses payments.

Rising also submits required reports to CMS and ensures compliance. It recognizes that not every Medicare Set Aside requires professional management, so it offers support if you decide to self-administer your account.

Ease Your Burden 

Understanding Medicare can be challenging in the best of circumstances. Add in a Medicare Set Aside, and confusion grows. Medicare Set Aside helps you if you suffer injury, illness or disease with the needs of future medical treatment. But that help comes with a heap of responsibility to secure proper pricing, adhere to reporting standards and make your Medicare Set Aside dollars stretch for the length of your life.

Dealing with an injury, illness or disease is daunting. Contracting professional administration services to administer your Medicare Set Aside erases your need to worry about reporting and compliance so you can focus on you. 

Frequently Aside Questions

1) Q: What are the different parts of Medicare?

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1) Q: What are the different parts of Medicare?
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Medicare has 4 parts named Parts A, B, C, and D. Part A provides hospitalization coverage while Part B provides outpatient coverage, like doctor visits. Parts A and B make up Medicare’s core coverages. Part C is provides private-market Medicare plans, called Medicare Advantage Plans. Part C coverage often includes additional benefits. Medicare Part D provides coverage for prescription drugs. Get a Medicare Insurance Quote through the top providers here.

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3) Q: Is Medicare free?

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3) Q: Is Medicare free?
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Because there are 4 parts to Medicare, there can be different cost structures. Most people won’t have to pay for Medicare Part A (hospitalization). Eligibility for premium-free Part A is based on your work history during which you paid Medicare taxes. Many people do pay a monthly premium for Medicare Part B, however, which covers outpatient medical services, like doctor visits. Deductibles also apply to services covered under Medicare Parts A and B, so you’ll pay a part of the annual cost.

Medicare Parts C and D are optional coverages and have premium costs of their own. Medicare Part C refers to Medicare Advantage Plans that offer additional coverage in exchange for a monthly premium. Part D, the prescription plan, reduces the cost of medications but also requires a monthly premium. Subsidies may be available for low income households to help reduce overall Medicare costs.

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3) Q: Do I need to sign up for Medicare?

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3) Q: Do I need to sign up for Medicare?
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If you signed up for Social Security before age 65, you were enrolled in Medicare automatically but benefits will begin at age 65. In most cases, there are penalties for not enrolling at age 65, so it pays to sign up on time. Click here to get a medicare quote in minutes from the best providers. 

If you have employer coverage, you may be able to delay Medicare coverage while your work plan is still in force. However, the size of the employer determines whether you’ll pay a penalty for not enrolling at age 65. Employees (and their spouses) of companies that offer group health insurance to 20 or more people are usually exempt from late sign-up penalties if they are covered by the employer’s plan.

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