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    After a work-related injury, you may require ongoing medical care, even after you’ve resolved your workers’ compensation claim. If your treatment continues, the question becomes: who pays for that treatment and for how long? For some workers, it makes sense for the workers’ comp insurance carrier to be responsible for future care. In other cases, injured workers may be better served by accepting a lump sum payment and taking over their own medical costs.

    In the workers’ comp system, this is a decision between accepting a clincher agreement or leaving your future medicals open. At Joye Law Firm Injury Lawyers, our South Carolina workers’ compensation lawyers review your unique needs and circumstances before helping you choose your best path forward.

     

    What “Future Medical” Means in a South Carolina Workers’ Comp Claim

    “Future medical” refers to treatment for a work-related injury that’s still needed even after you reach maximum medical improvement, or after your disability benefits are resolved. Depending on your injury, that can include surgery, injections, prescriptions, physical therapy, diagnostic imaging, pain management, medical equipment, and follow-up care. South Carolina law requires employers to provide qualifying medical treatment for covered work injuries, subject to the Workers’ Compensation Act and the terms of any settlement or order.

    Options for Handling Future Medical Care

    At the end of a workers’ compensation claim where future medical costs are expected, there are a few options on how those future medical bills will be handled. Injured workers can “Leave Future Medical Open” or use a “clincher” agreement to pay a lump sum upfront. They may also need to create a Medicare set-aside account to protect their future Medicare benefits. Read on to understand the pros and cons of these options and how to best protect your right future medical care.

    Leaving Future Medical Open

    While you may want to settle your case completely and receive a lump-sum payment for your future medical coverage, you are not required to do so. In fact, there is no requirement mandating that you accept a lump-sum payment for future medical costs. Likewise, there is nothing that requires the workers’ compensation insurance carrier to pay a lump sum to settle this aspect of a case.

    In many cases, your South Carolina workers’ compensation lawyer at Joye Law Firm Injury Lawyers will instead advise you to request a hearing before the South Carolina Workers’ Compensation Commission. The Commission can decide your claim for disability benefits and may protect your right to ongoing payment of medical bills. This can be beneficial because Medicare may not fully cover certain types of ongoing treatment costs, such as prescription expenses.

    In order for the Commission to award you ongoing medical coverage, your treating physician must prepare a summary report or complete a Form 14B using very specific language. Your doctor must specify that your future medical treatment needs are expressed in the form or in the summary “to a reasonable degree of medical certainty.”

    While doctors may overlook this question or fail to use proper language, failure to fill out the form completely or failure to use the correct language may hinder your claim and prevent you from being awarded ongoing or future medical coverage. This is why it is so important to have a South Carolina workers’ compensation attorney if your injury requires ongoing treatment. Your lawyer can work to ensure your doctor has completed all forms correctly or can otherwise take action to protect your rights and make sure that all future medical costs are covered.

    There is another caveat to be aware of when considering leaving medical open, too. If there’s a lapse in treatment exceeding one year, this benefit becomes null and void. Our experienced workers’ comp lawyers have guided numerous clients through safeguarding this coverage. This is particularly critical for disabling injuries, which may worsen over time. Even if you don’t currently require injections or surgery for your work injury, extensive treatment might be necessary in the future. Allowing a lapse in coverage means bearing these expenses out of pocket through your own health insurance.

    In South Carolina, the settlement form matters. A Form 16 or Form 16A can resolve permanent disability or disfigurement while preserving a limited right to seek additional benefits. Under S.C. Code § 42-15-60, an employer is not required to provide further medical treatment more than one year after full payment of a Form 16 or Form 16A settlement unless the agreement specifically says otherwise.

    Keeping medical responsibility open under a settlement or order may make sense when your doctor expects ongoing medication, injections, replacement hardware, or surgery that cannot yet be scheduled. It can reduce the risk of having to fund expensive care yourself. The trade-off is that treatment may stay within the workers’ compensation authorization process, and disputes can arise over whether later care is related to the original injury.

    How a Clincher Agreement Works in South Carolina

    A full and final Agreement and Release is often called a “clincher.” It closes a South Carolina workers’ compensation claim in exchange for a negotiated settlement. Unless the agreement specifically preserves certain benefits or obligations, it generally ends the employer’s responsibility for future compensation and medical expenses.

    Settlement paperwork must be filed with the South Carolina Workers’ Compensation Commission. Once the clincher is approved and certified as binding, the worker generally cannot seek additional payments later just because their medical condition worsens.

    Before a settlement is finalized, the medical record should show where your recovery stands and what treatment may still be needed. A Form 14B physician’s statement can document permanent impairment, work restrictions, and future medical needs. You should also identify unpaid authorized bills, pending procedures, prescriptions, and any treatment recommendation that is not yet reflected in the settlement.

    Before signing, make sure you know exactly which medical rights are closing, which obligations remain open, and how Medicare or other coverage may fit in. If Medicare has an interest in the claim, that review may include a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA).

    A clincher can provide finality and a lump-sum payment. It may also give you more control over where you seek care after the workers’ comp insurance carrier’s responsibility ends. However, the money needs to last a lifetime, not just until your next appointment. You must consider all projected procedures, medication, therapy, equipment, provider charges, and any future costs Medicare may not cover.

    When Medicare Is Involved: Workers’ Compensation Set-Asides

    Traditionally, when a workers’ compensation insurance company settled a claim with a disabled worker, they would pay a small amount for future medical expenses with the expectation that future treatment would be covered by Medicare, the federal insurance system that provides coverage for senior citizens and disabled Americans.

    Unfortunately, assuming Medicare will cover future treatment is a big risk. The bottom line is that the future of the Medicare is uncertain. The program is experiencing serious financial uncertainty, and the problems with the system are likely to grow in the next 10 years or 20 years. Even if it continue to exist, there are no guarantees that it will cover future treatments you need for your work-related injury.  In fact, Medicare is more frequently pushing back against being forced to assume responsibility for paying for injured workers’ treatment costs. Instead, they are aiming to shift more of this responsibility back onto workers’ compensation insurers.

    Due to these risks and complications, workers’ compensation insurers have now begun the practice of setting up Medicare Set-Aside Accounts in larger workers’ compensation settlements.

    A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) allocates part of a workers’ compensation settlement to future medical services for the work injury that Medicare would otherwise cover. The Centers for Medicare & Medicaid Services (CMS) describes a WCMSA as the recommended method for protecting Medicare’s interests in settlements that include future medical expenses.

    • CMS will review a WCMSA proposal when the claimant is already a Medicare beneficiary, and the total settlement is greater than $25,000.
    • CMS will also review a proposal when there is a reasonable expectation of Medicare enrollment within 30 months and the anticipated total settlement amount is expected to be greater than $250,000.

    How to Set Up a Medicare Set Aside in a Workers’ Comp Case

    To set up these accounts, the insurance company asks a life-care planner to estimate what types of Medicare-covered treatments an injured worker will need over the course of his or her lifetime. Once approved by the Centers for Medicare and Medicaid Services (CMS), the workers’ comp insurance company will pay the amount of money approved by CMS. However, the injured worker is required to put this money into a special Medicare Set-Aside Account. The account is an interest-bearing account that can be used only to pay for treatment expenses incurred due to the work injury. The expenses must be paid at the same rate as Medicare would pay. Only after the money in the set-aside account has been properly spent will Medicare kick in to cover treatment for work injuries.

    Everything about these set-aside accounts is very complicated. Determining future covered costs under Medicare is not an exact science. Also, there are often future treatment costs that would not be covered by Medicare, frequently referred to as “non-covered costs.” In most cases, an experienced disability attorney can help an injured worker receive more money to settle their future medical coverage rights than they could on their own. Your attorney may advise working with an independent medical examiner or life care planner to provide a different, more accurate estimate of what the covered costs will be, so a larger settlement can be obtained. Also, your attorney may advise you against settling your future medical coverage rights if it’s in your best interest to keep your workers’ compensation coverage intact. Every situation is different.

    Once the Medicare Set-Aside Account has been set up, it can also be complicated to manage the account and to prove to Medicare that it has been properly exhausted. Your workers’ compensation lawyer can advise you on this process as well.

    Decision point Future open medical Lump-sum clincher Medicare Set-Aside
    Who pays later The carrier pays covered, authorized, injury-related care for the period and services protected by the settlement or order. You use settlement funds for future care after the clincher ends the carrier’s responsibility. Funds set aside during the Workers’ Compensation Settlement process in a Medicare Set-Aside are first exhausted before Medicare begins to cover.
    Doctor access Treatment usually remains within the workers’ compensation authorization process. You may have more freedom to choose providers, but you become responsible for the cost under the settlement terms. Treatment usually remains within the workers’ compensation authorization process.
    Main advantage Protection against treatment costs that are hard to predict today. A defined payment and an end to ongoing claim administration. Protection against the uncertainty of long-term availability of Medicare funds. Expenses must be paid at the same rate Medicare would pay, making the money go further.
    Main risk Disputes may arise over authorization, causation, or whether later care remains covered. The payment may not match later costs, and a full and final release generally closes future rights. Disputes may arise over authorization, causation, or whether later care remains covered.
    Questions to test What care is protected, for how long, and through which authorized provider? What treatment, medication, equipment, and Medicare obligations must the payment cover? How to prove a Medicare set-aside has been exhausted? What happens after those funds are exhausted?

    What Happens If You Settle Too Early

    Settling before you understand your long-term medical needs can leave you with a settlement that does not match the cost of your future care. That risk is especially serious if you have not reached maximum medical improvement, your doctor is still evaluating surgery, or your condition requires ongoing medication, injections, or equipment.

    With a full and final clincher, you cannot return to the Commission for more compensation or medical payments simply because your condition worsens. A settlement that looked adequate when you signed it can become expensive if treatment changes or complications develop.

    If Medicare is involved, a poorly planned settlement can create a second problem: bills may be denied, or Medicare may seek repayment of conditional payments. Before you sign, make sure the settlement addresses both the workers’ compensation obligations and Medicare’s role.

    How We Protect Your Future Medical Care After Your Workers’ Compensation Case Settles

    Our South Carolina workers’ comp team at Joye Law Firm Injury Lawyers is among the best in the business. Matt Jackson, who leads the department, is a Past President of Injured Workers’ Advocates and was selected by Best Lawyers as the 2024 “Lawyer of the Year” for Workers’ Compensation Law – Claimants in Charleston. Our team reviews settlement language against the authorized treatment record, recommends specific workers’ compensation forms and strategy to pursue, future prescriptions and procedures, Medicare status, conditional payment information, and care that may fall outside Medicare coverage.

    That review may include taking the case to a hearing before the Workers’ Compensation Commission, asking for clearer medical opinions, checking whether the treating physician’s recommendations match the proposed agreement, identifying unpaid bills, and testing the assumptions behind a lump-sum medical allocation. We ensure that every injured worker’s settlement terms have their best interest in mind and we work to make the trade-offs clear before the agreement becomes binding.

    Joye Law Firm Injury Lawyers has represented injured South Carolinians since 1968. We have earned Regional Tier 1 rankings for Workers’ Compensation Law – Claimants in Charleston, Columbia, and Greenville in the 2026 Best Law Firms rankings. Managing Partner Ken Harrell was also named Best Lawyers’ 2026 “Lawyer of the Year” for Workers’ Compensation Law – Claimants in Charleston.

    The values behind our firm culture show up in how we work with people facing decisions about future medical care. We make room for the questions and uncertainty that can come with long-term treatment, and we treat those concerns as part of the case rather than an afterthought. At the end of the day, this is more than an injury. It is your life and your future. That’s why our goal is simple: to get you the most money possible.

    If you have questions about a proposed workers’ compensation settlement, bring the draft agreement and your current medical information to a lawyer before you sign. Joye Law Firm Injury Lawyers offers free consultations to injured workers across South Carolina.

    Frequently Asked Questions

    WC - Future Medical

    What does “future medical” mean in a workers’ comp settlement?

    “Future medical” means injury-related medical treatment that will be paid for by the employer or workers’ comp insurance carrier after a worker’s disability benefits are resolved, but the exact scope depends on the settlement or order. In a Form 16 or Form 16A settlement, South Carolina law generally limits further medical treatment to one year after full payment unless the form specifically provides otherwise. A clincher usually closes future medical unless the agreement preserves it.

    Can I settle my workers’ comp case and still keep my medical coverage open?

    Yes, but the details matter. A Form 16 or Form 16A can preserve some rights after a permanency settlement, and the document can specifically provide for further medical treatment. A clincher generally closes future medical unless it says otherwise. Ask a South Carolina workers’ compensation lawyer to review the actual agreement before you sign.

    Is a Medicare set-aside required by law?

    No. CMS states there is no statute or regulation requiring a WCMSA proposal to be submitted for review. The parties still must protect Medicare’s interests under Medicare Secondary Payer rules when a workers’ compensation settlement includes future medical expenses.

    How much of my settlement has to go into a Medicare set-aside?

    There is no fixed percentage. A WCMSA is based on the facts of the case, including anticipated Medicare-covered treatment for the work injury. Medical records, physician recommendations, medication history, and projected costs can all affect the amount.

    What happens if workers’ comp stops paying but Medicare says workers’ comp is primary?

    It depends on why payment stopped. Workers’ compensation generally pays first for accepted work-related care, but Medicare may make conditional payments in some circumstances while responsibility is resolved. Keep the carrier’s written denial, Medicare notices, medical bills, and claim documents so the payment issue can be addressed.

    What is a clincher agreement in South Carolina?

    A clincher is an Agreement and Final Release that generally ends future workers’ compensation and medical responsibility unless the document says otherwise. The settlement is filed with the South Carolina Workers’ Compensation Commission and, once approved and certified as binding, normally prevents the worker from seeking additional payments later because the condition worsened.

    What happens if the money in my set-aside runs out?

    If a WCMSA is properly funded and administered, Medicare may begin paying for otherwise covered work-injury care after the set-aside funds are properly exhausted. Administration and reporting rules matter. Spending the account on non-allowable items or failing to keep required records can create payment problems.

    Talk to a South Carolina Workers’ Comp Lawyer Before You Sign

    A workers’ compensation settlement can trade future rights for finality. Before you sign, make sure you understand what happens to your medical care, any unpaid bills, future wage benefits, and Medicare coverage.

    Joye Law Firm Injury Lawyers has represented injured thousands of South Carolinians since 1968. Our workers’ compensation lawyers can review your proposed settlement, medical records, and Medicare issues with you. If you’re worried whether a settlement could shift future medical costs onto you, schedule a free consultation with our lawyers.

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