workers comp lump sum settlement/ medicare set-aside account

[Dutchy]

kate Wrote:CMS reviews settlements in the following situations:

* The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; OR

* 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/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.

An individual has a "reasonable expectation" of Medicare enrollment if any of the following situations apply:

(a) The individual has applied for Social Security Disability Benefits;

(b) The individual has been denied Social Security Disability Benefits but anticipates appealing that decision;

© The individual is in the process of appealing and/or re-filing for Social Security Disability Benefits;

(d) The individual is 62 years and 6 months old (i.e., may be eligible for Medicare based upon his/her age within 30 months); or

(e) The individual has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.

A WCMSA should be placed in an interest bearing account. WCMSAs should also be administered by a competent administrator (the representative payee, a professional administrator, etc.). When a claimant designates a representative payee, appointed guardian/conservator, or has otherwise been declared incompetent by a court; the settling parties must include that information in their Medicare set-aside arrangement proposal to CMS.

In addition, the claimant may self-administer his or her own WCMSA, if permitted under State law. Claimant should submit an annual self-attestation form when monies have been exhausted.

[Dutchy]

In our case, my husband was on SS disability in April 2006 until Nov2007 when he became eligible for regular SS benefits.

1. Do you think it is adviseable to self-administer our MSA through our local bank. It's under 5K .
2. Is it true that you only submit paid bills for reinbursement to your bank or is it more detailed?
3. All the questions you listed are on our settlement form except 11 and 12.
4. With a lump sum payout does SS benefits gets reduced? My husband is on regular SS benefits now for 1 1/2 yrs. and it was 1 1/2 yrs on SS diability.
5. Thanks a lot...where fo you obtain an annual self-atestation form?
6. Is the settlement always in two parts ideminity and medical? I'm under the impression that its all medical because of the 10% requirement of total settlement for MSA

[Dutchy]

kate Wrote:The amount of the set aside is determined on a case-by-case basis and should be reviewed by the Center for Medicare and Medicaid Services (CMS), when appropriate. Once the CMS determined set aside amount is exhausted and accurately accounted for to CMS, Medicare will agree to pay primary for future Medicare covered expenses related to the WC injury.

If the IC does not get approval for the set aside amount, they are usually responsible for any costs above that.

[Dutchy]

Kate, AH it's finally sinking in and apparently I was too rattled to comprehend at the time. Now I get it..I think..Pre-approval by CMS is crucial for the MSA account amount to prevent the entire workers comp settlement from being exposed by medicare for all future medical bills. Great, great advise and it was backed up by other very generous participants. Thanks a million. Took a hot fudge sundae to get the cobwebs cleared. LOL Thanks

[Dutchy]

Still in Limbo Wrote:Dutchy Hi and Welcome to the Forum!! Kate and MJC are giving You Great Info., I'm on SSDI and w/c, and in My State, (I'm not Sure if You Posted Yours) We have the Choice with a Lump Sum Settlement of the Ins. Co, continuing the Medical, or a Medicare Set-Aside. It's such a Difference on a Case by Case Basis, it would be Very Hard to give You the Best Way to go, but if You Trust Your Attorney follow Their Lead, if You Don;t Trust them, get a Second Opinion before You Sign Anything. You May have to Pay another Attorney for the Second Opinion, but it would be Well Worth it! I'm Totally Disabled from My injury, and only 47, so My Set-Aside or Future Medical Care is going to be Astronomical if I Settle, that's Why they are Fighting Me so Hard, and Buying Time, Hoping I get Frustrated and want to Settle for Less, that's about the only Reason I can Find for it any way! Best of Luck, You will get Great Info. Here!!

[Dutchy]

Thank you still in limbo! Sorry to hear of your disability at such a young age. Lucky for us we benefit from your experiences. I am in RI and the Employer is self-insured.. so no insurance company is involved. Apparently this medical set-aside account is because it is not the purpose or responsibility for payments by Medicare of medical expenses for the treatment of work-related conditions. I gather that this settlement goes before a judge to review the federal aspect of it and than it goes to the state of RI workers compensation board. Our attorney over simplified this MSA. Thanks again for your help. You guys are doing an extraordinary public service.

[Dutchy]

kate Wrote:MJC,
Yes, pretty much the jist of it, although in some cases, the injured worker can "self-administer" the funds instead of a third party. (Not recommended).

And even in your case where there may be future surgery necessary, you could settle with an MSA. They need to take into account any future needs, inflation, prescriptions, etc. In serious injuries, the IC usually has to get a "life care plan"

To submit a MSA for approval the submission should include:
1) A Cover Letter with the following information:

* Claimant’s Name
* Claimant's Date of Birth
* Claimant's Health Insurance Claim Number (HICN) or Social Security Number
* Claimant’s Address and Phone Number
* Claimant’s Counsel Information
* Entitlement Information
* Employer's Information
* WC Insurer
* State of Venue
* Attorney Representing Employer or WC Insurer
* Injury/Disease Date
* Type of Injury/Disease
* Total WC Settlement Amount
* Proposed Medicare Set-aside Amount

2) Evaluation of Life Expectancy
3) Claimant Release Form
4)  Life Care Plan (If the claimant’s injury/disease is extensive/serious)
5)  A copy of the proposed settlement agreement.
6) Current and Future Medical Treatment
7)  Patient Medical Recovery Prognosis
8) Total Settlement Amount.
9) Identify the total amount of the settlement that is designated for future medical benefits and how calculated
10) Medicare Set-aside Amount
11) Designate the administrator
12) Medicare Set-aside Arrangement Account
13) Fees

Does this help?

[Dutchy]

Kate, why do you not recommend "self-administered" MSA account. The employer is self-insured and no insurance company is involved. The amount of MSA is under 5K