Cap. Medicare Set-Aside.

[Still in Limbo]

When a Medicare set-aside is calculated, they use a system, I don't know exact terminology, but I do know how it works, My Attorney explained it to me. They take the average of your Husbands past Medical Bills, take into account if any surgeries may be needed in the Future, and take into account His average Life Span. Medicare then has to approve that these figures are acceptable, they won't let the i/c short change your Husband, and at that point the next step happens. If the i/c accepts and goes along with the set-aside, the Approved amount of Monies are put into a interest bearing account that your Husband is in charge from. I don't want to make this too confusing, but I'm going to throw out an example, just numbers for comparison, your Husbands numbers I'm sure will be different

Let's say Yearly Medical bills are $5,000.00 and they expect your husband to live an additional 15 years. The set-aside account will be $75,000.00 which your Husband will have full control over. From that point on, Your Husband pays his own Dr. bills from that account. Let's say the first Year he spends $7,000.00 in Medical Bills. $5000.00 (the average will come out of his account. $2,000.00 will be paid by Medicare) if year two he only spend $3,000.00 on Med. Bills, the additional $2000.00 rolls over into the account for next year. So the Next year he has to spend $7,000.00 before Medicare will pay. and this goes on every Year, it may sound confusing, but if you read over it a couple of times, it will make sense.


Now, should Your Husband pass on, and there is let's say $45,000.00 left in the account, that money goes to his Beneficiary in a lump sum. If you leave Medical open with w/c, they control every aspect of his care, and he has to get approval for any appts., etc. and if he should Pass, the Family gets nothing. And you can bet your bottom Dollar they will be constantly sending him for w/c Dr. check-ups, trying to get him "Healed" so they no longer have to pay. So as you can see, with him being on SSDI as I am, the set-aside is the only true way to go to Protect his care and the Family should he Pass. If you have any questions, please post here, or you can certainly PM me, and I will explain more!! As always I wish you all the Best, and I hope this isn't too confusing, and it clears things up for you a bit!!

[capricorn]

Thanks my friend, great explanation but of course you know I have more questions. Let's say hubby doesn't see the Dr. for a year or two and spends nothing. Or WC puts $75,000 in this acccount that he never uses. What I am understanding is that hubby would never be able to use the money for anything but his medical and in the end it would go to a named beneficiary??? Do I have it? His attorney said something to him in passing that IF he chooses to just outright settle it, the IC would give him a nominal amount, let's say $10,000-$15,000. ??? This hasn't been discussed in any detail with his attorney as the IC just made their move recently. I do understand what your are saying and it appears to me that a set-aside is the best way to go. Hubby would never agree to keeping the WC IC in charge of his trash let alone his life Right now he is in the process of having some tests done and making decisions. He doesn't lile the neuro who did his surgery so is in search of another opinion to the last MRI which showed extreme deterioration in the past year and some nerve compression at 3 levels, plus spurring and herniation which weren't there a year ago. PM Dr. would like him to follow up with a neuro or ortho. The spine specialist I see is the best in the area. He is who I would like Hubby to follow up with BUT this Dr. has a policy of not treating anyone who has had surgery done elsewhere. I would like him to know where he stands from an ortho's opinion instead of just the PM Dr. Just looking out for his welfare. I feel he will need another surgery one day. I'm no expert and know most of what's going on is extreme arthritis in the lower spine so I also know nothing can be done. Decisions, decisions.

CAP

[genegene]

Limbo...You are awesome...You just explained more in those couple of paragraphs than I've been able to learn in 2 years. Basically I need to get my surgeries, keep the SSDI app in place and let WC put money in an account for future medicals. Bless you

[capricorn]

Gene....we must have been posting at the same time. I was hoping you would see this. Limbo is awesome! Best explanation I have ever gotten. It sounds like you are on the right track now.

God bless,
CAP

[genegene]

I feel the best I have felt in a long time and it feels great. Knowledge is power and Thank God there are alot of people who are smarter than I am about this stuff.

[capricorn]

Gene...I totally agree. After being in the system myself for the 5th time and going through over 3 years with Hubby I have learned more here than anywhere else. My attorney asked my husband if he could talk to me all the time because i am WC savvy. I have to tell him where I learned everything.

CAP

[Still in Limbo]

Thanks for the kind words guys, I really appreciate it. Cap. as Injured Workers ourselves we know follow-up and possibly Pain Management is in your Husbands future. That's why they take the average amount he is spending now for his care, (The dollar amount, whether he is paying himself or w/c or his Private Insurance) to come up with what he is going to need in the future. If he doesn't see a Dr. much now, his set-aside is going to be lower than let's say mine, with 1200.00 per mo. in Meds. and the three Dr,'s I see. They also look at his injury, and plan for any known complications that may occur over time, that's why Medicare has to approve it, they are not going to let w/c put 10-15k in the account if they feel your Husband is going to need 30-40k for his injury in the Future. This Money is audited every Year, so it can only go for Health Care for Him, but as I said on his passing the lump sum goes to his Beneficiary. The figure will be very close to what he needs, Medicare won't allow any less! I hope this answers your questions, and please feel free to ask away if you ahve any more!!!

[MJC]

Limbo,

Thanks for coming to the rescue! Everything you have said was also told to me when I came to setteling my indeminity (wages) portion of my claim. You have a memory that is as sharp as a tack because I could not remember all of what you said to try and help Genegene for sure. I was grabbing pieces from the top of my head. That does not always work to well for me with all the meds I take.

All I have to say is this. If Limbo said it and explained it to you, YOU CAN TAKE IT TO THE BANK! So happy you are back to share your wealth of knowledge with others that need your help.
Take care and God Bless You, Limbo!

Cajun Hugsssssss,
MJC

[genegene]

Thats another lie I have been told. They told me that if they put money in a set-aside that if anything happens to me everyone is out of luck. Obviously just the opposite is true. Thanks guys.

[Still in Limbo]

Thanks MJC!!! And Gene, you have to put all of your energy into finding better Counsel and NOW!! These people talking to you, (Your Attorney and the w/c Attorney) are leading you down a dead-end road! I wish you the Best in getting this resolved!!