Hello There, Guest! Login Register
Index    |     Search    |     Members    |     Help

Thread Rating:
  • 0 Vote(s) - 0 Average
  • 1
  • 2
  • 3
  • 4
  • 5
Workers Comp, BC/BS and Medicare
#1
I am a Nurse Case Manager. I have a client who sustained an injury to her knee about 7 years ago. She had multiple torn meniscus and ligamentous injuries. She ultimately received a settlement from Workers Comp. Secondary to her knee injury she developed severe degenerative arthritis to her knee and will need total knee replacement. It has severely impacted her quality of life. Her spouse has BC/BS but will retire in 12/18. Can she get this surgery under BC/BS or is this still W/C ? Additionally she will be eligible for Medicare in 2019, will Medicare pay ? Is the subsequent degenerative arthritis considered a new condition. Thank you in advance for your help.

William J Guage RN , BS , CCM
 
Reply
#2
Not enough back ground info.............Open medical? ........ MSA?... Settlement?..... etc.....

If your going fishing you need to use more bait...........
 
Reply
#3
What state?
is the original case closed?
How is her current treatment being paid?
It's not workers comp until carrier or comp court accepts it.
Determination requires medical evidence. Disputed evidence is resolved by comp court.
if treatment $$ were included in settlement, she may have to account for their use prior to Medicare extending coverage for the work injury.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#4
I think it is a safe bet to say Blue Shield/ Blue Cross will absolutely not cover a work related injury without reserving their reimbursement and subrogation rights. This is in the Evidence of Coverage within the insurance contract.

BC/BS insures the husband. Maybe the wife? Not the wife's work injury?Every private insurance contract I have ever seen specifically excludes injuries or illnesses that arose out of the course of employmet.

Medicare will absolutely not cover a work injury without a MSA in place .First thing Medicare is going to do is list the comp carrier as the Primary Insurance.

Absent the knee surgery would the arthritis be present? Surgery actually speeds up the process. Would a replacement be needed? No one here can give medical advice to your question.

Since you are a NCM she must have an open medical correct ? If she has an open medical it's on comp . If she sold the medical its on her.

I think its impossible to shift a work injury in to private insurance..Actually I challenge anyone to show me a ( proof positive ) case where they did, legally of course, within the contracts / medical insurance provisions.

I was taught that no insurance company will accept liability for a loss that another insurance company holds liability for.

Please take good care of your injured worker. She will need your help as a Health Care Provider post Worker Comp financed knee replacement.

Just my opinion here . If I am wrong , I take full responsibility. I am just another injured worker too.

Without the state its hard to say ?

Looks like you are in New York?

Good Luck
 
Reply
#5
Glad we were able to help, thanks for posting.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#6
(02-19-2018, 10:52 AM)goingback Wrote: Not enough back ground info.............Open medical? ........ MSA?... Settlement?..... etc.....

If your going fishing you need to use more bait...........

HI: Thanks for the response. The state is NY. There is no MSA, case is closed , medical is closed, a settlement was made based on "protracted healing." The initial injury was torn meniscus. This accelerated already present degenerative arthritis . In the words of the client " Is this knee problem going to be workman's comp until I die"?( She is in her late 60's). Are their other areas of inquiry you can recommend? Thank you in advance for your help and input.

Bill Guage RN, CCM
 
Reply
#7
if it was a lump sum buyout of all benefits, then the $$$ cover all future obligations/benefits of the employer/carrier and there is no second chance for more. the section 32 settlement papers should have made that clear.
http://www.wcb.ny.gov/content/main/Worke...orkers.jsp
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#8
She can use the money she received to pay for her medical care .

When she took the money she accepted liability for her future medical needs without a MSA.

Please let us know if another carrier knowingly accepts liability . Medicare, Medicaid, or private insurance.

I have been looking for years of a workers comp claimant that sold the future medical and legitimately has is it covered elsewhere.

Or a private health insurance policy that does not exclude work related illnesses or injuries.

I am just an injured worker looking for this answer too.

I though the video 1171 posted was good and factual.

Good luck
 
Reply
#9
To add to 1171's answer, Medicare will NOT pay for future medical treatment unless you follow the MSAA rules AND prove that you are out-of-pocket for future medical treatment in an amount equal to or greater than the amount of the set aside.

If the WC lump settlement is under $250K, and the parties agree NOT to secure Medicare’s approval in advance, there is a risk that Medicare will decide that the amount of the set aside for future medical treatment is NOT enough to protect their interest. This could impair your right to have Medicare pay for future medical treatment after you exhaust the amount of the set aside.

Every private health insurance contract is different. Thus, you would have to look to the terms of the policy first.
That being said, it is possible that a private health insurance company likewise would refuse to pay for any future medical treatment unless you prove that you are out-of-pocket for future medical treatment in an amount equal to or greater than the amount of the set aside.
If your work related injury is preexisting, a private health insurance company may refuse to insure you or may preclude you from being covered for any future medical treatment.

http://modicalawfirm.com/what-if-i-settl...-all-time/
 
Reply
#10
(03-03-2018, 05:27 PM)goingback Wrote: To add to 1171's answer, Medicare will NOT pay for future medical treatment unless you follow the MSAA rules AND prove that you are out-of-pocket for future medical treatment in an amount equal to or greater than the amount of the set aside.

If the WC lump settlement is under $250K, and the parties agree NOT to secure Medicare’s approval in advance, there is a risk that Medicare will decide that the amount of the set aside for future medical treatment is NOT enough to protect their interest. This could impair your right to have Medicare pay for future medical treatment after you exhaust the amount of the set aside.

Every private health insurance contract is different. Thus, you would have to look to the terms of the policy first.
That being said, it is possible that a private health insurance company likewise would refuse to pay for any future medical treatment unless you prove that you are out-of-pocket for future medical treatment in an amount equal to or greater than the amount of the set aside.
If your work related injury is preexisting, a private health insurance company may refuse to insure you or may preclude you from being covered for any future medical treatment.

http://modicalawfirm.com/what-if-i-settl...-all-time/

https://www.healthcare.gov/coverage/pre-...onditions/

The above has information about pre-existing conditions. Grandfathered policies ended on 2014. Unless you purchase private insurance outside of the enrollment period they should cover pre-existing conditions.

"All Marketplace plans must cover treatment for pre-existing medical conditions.
•No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started.
•Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health."
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
Reply
  


Possibly Related Threads...
Thread Author Replies Views Last Post
  Workers Comp Violation? Floydmay22 2 380 11-17-2018, 05:14 PM
Last Post: California_Help
  Built a map of workers comp. John_Richardson 0 295 10-01-2018, 12:43 PM
Last Post: John_Richardson
Sad Workers comp settlement amount help Jayal27 4 714 09-07-2018, 04:06 PM
Last Post: 1171
  Workers Comp. running out in Calif. C3d 3 742 08-20-2018, 01:11 AM
Last Post: 1171
  IME report/Workers comp/employer debikayluo 6 6,995 06-07-2018, 10:13 AM
Last Post: tinainky
  NJ Workers Comp Question mcats 32 8,132 06-06-2018, 05:01 PM
Last Post: 1171
  Workers Comp Adjuster (Arizona) 241050 9 1,404 05-20-2018, 12:07 PM
Last Post: 1171
Shy Work related/induced stress & workers comp heartworkerNC 6 3,086 03-21-2018, 07:39 PM
Last Post: 1171
  Re injured myself (not the workers comp injury) 241050 3 1,319 03-10-2018, 12:45 AM
Last Post: 1171
  NC workers comp question Cwayman21 4 1,455 02-14-2018, 05:30 PM
Last Post: Cashiered Too

Forum Jump:


Browsing: 1 Guest(s)