Medicare Secondary Payer Statute and Workers Compensation Settlements

One of the hottest topics in workers' compensation law in all 50 states is the impact of Medicare on workers' compensation settlements. When a workers' compensation claim is settled and certain thresholds are met, consideration of the Medicare Secondary Payer Statute is critical. Workers' compensation lawyers and insurance carriers must determine whether a settlement requires approval by Medicare and whether a Medicare set-aside is appropriate. The failure to take the appropriate steps can result in the denial of future Medicare payments to the claimant as well as liability and penalties on the employer, workers compensation insurance carrier and the attorneys handling the claim.

This web site is unique because it does not simply provide a one dimensional analysis of the application of the Medicare Secondary Payer Statute to workers' compensation settlements. MedicareApproval.com provides a multi-dimensional and interactive guide through the analytical process of determining the impact of the Medicare Secondary Payer Statute on your particular case. Please note, however, that all use of this web site is subject to a broad DISCLAIMER.

The analysis of the Medicare issues related to a workers' compensation settlement is two-fold. First, does the claim fall within the Medicare thresholds and such that approval by CMS is required? To answer this question, click "Do I need Approval?" from the main menu above and begin the interactive process.

Second, if you have determined that approval by CMS of a your workers' compensation claim is required, click "Services" above to learn more about how to get the job done right with professional assistance.

NEW: Medicare Set-aside Decision Flow Chart

August 11, 2010- Top Ten Submitter Errors
An updated Top Ten Submitter Error document has been provided by CMS. more..

July 9, 2010 - New Life Tables
The Centers for Disease Control (CDC) has recently published its 2006 United States Life Tables. Effective July 19, 2010, any newly submitted WCMSA proposal received by CMS' Coordination of Benefits Contractor (COBC), or where any WCMSA case is reopened on or after July 19, 2010, CMS will apply the CDC's 2006 Table 1 for life expectancy calculations. You may access the CDC's United States Life Tables at by clicking here.

New Operating Rules Memo
12-19-08: CMS posted the "Operating Rules" memo dated 10-27-08 used by its workers' compensation review contractor. more..

New Policy Memo
8-24-08: CMS issued a new memo clarifying its policy regarding "Beneficiaries that Request Termination of a WCMSA Account". more..

New Policy Memo
5-20-08: CMS issued a new memo clarifying its policy regarding life expectancy calculations. more..

New Policy Memo
7-24-06: CMS issued a new memo clarifying its policy regarding the inclusion of prescription expenses in Medicare set-asides. more..

New Medicare Threshold
4-25-06: CMS revised the workers' compensation settlement approval threshold for Medicare beneficiaries from $10,000 to $25,000. more..

Prescription Medications
12-30-05: CMS released a formal policy memorandum regarding prescription drugs. It now requires that All WC settlements that occur on or after January 1, 2006, must consider and protect Medicare’s interests when future treatment includes prescription drugs along with the future medical services that would otherwise be reimbursable by Medicare. more..

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Medicare Decision Flow Chart

Comprehensive Article

If you determine that CMS approval of your settlement is required, with or without a set-aside, it is critical that you obtain professional counsel to guide you through the process. This is especially true for high exposure cases where the amount of future medical exposure is significant. The failure to take appropriate precautions can cause unnecessary delays in finalizing settlements and can create unnecessary exposure to the claimant, claimant's counsel, the employer, the insurance carrier and their counsel. more..