Workers' Compensation Discussion Forums
Medical set-aside inquiries - Printable Version

+- Workers' Compensation Discussion Forums (https://www.workerscompensation.com/forums/general)
+-- Forum: Category (https://www.workerscompensation.com/forums/general/forumdisplay.php?fid=3)
+--- Forum: Injured Worker Forum (https://www.workerscompensation.com/forums/general/forumdisplay.php?fid=4)
+--- Thread: Medical set-aside inquiries (/showthread.php?tid=18004)



Medical set-aside inquiries - Andy1689 - 08-31-2019

Does anyone in the forum settled with WCMSA? If so, what was the outcome? Did Medicare give you a hard time to approve the medical treatments like surgery, physical therapy and nursing home in the future etc.? Did you hire anybody to manage your WCMSA account? Do you think WCMSA or open medical is better? Sorry for so many questions, I need to make a decision soon, thanks in advance.


RE: Medical set-aside inquiries - 1171 - 09-02-2019

FYI:
If the set aside amount is adequate, you’ll never get to a point where you need medicare; medicare is just a contingency when there is a set aside.


RE: Medical set-aside inquiries - Andy1689 - 09-02-2019

(09-02-2019, 05:56 PM)1171 Wrote: FYI:
If the set aside amount is adequate, you’ll never get to a point where you need medicare; medicare is just a contingency when there is a set aside.

The set aside amount is not adequate, and when I get older my situation will get worse, I might need a surgery or go to the nursing home.... I’m so confused with Medicare and Medicare with AARP. I asked my current Medicare with AARP insurance company, the rep told me they will cover 100% after set aside money exhausted, but I was told by CMS I need to report to Medicare which’s only covered 80%. Don’t know who should I trust, if I need to pay 20% out of my pocket and I will reject the settlement.


RE: Medical set-aside inquiries - California_Help - 09-02-2019

Medicare is similar to private insurance, you will have co-pays and a deductible. You can purchase a secondary Medicare insurance to help cover those costs as many seniors do( after your MSA is used).

Work comp does not cover everything either. Your doctors requests will be subject to Utilization Review in your state. I have seen another member from your state get most things denied recently through the UR system, which leaves them without basic testings for her injury.

So weigh out your options because having open medical in work comp does not mean everything is covered. The UR system is very strict in some states. You would know better how dealing with medical in this system has been for you and if you want to continue without an attorney with open medical. Some injured workers prefer open medical.

The Medicare set aside only covers things that are normally covered by Medicare. If you are worried about the things that are not covered by the MSA, then you can talk to your attorney about structuring the settlement with coverage that is settlement money for medical treatment and costs not covered by the MSA(which does not affect your SSDI as it is not income). These donut hole type monies can be given to you to use (and you can use it for whatever you want). You do not have to report payments to Medicare for treatment for this money as it is for things not covered by Medicare. Just an idea. I am no expert.

Also, you only need to take Medicare's interests into account and do not have to have a MSA approved by CMS (but many attorney's recommend). Some attorney's are just doing Medicare proposals and not have them submitted to Medicare for approval. This is being done because they found Medicare has come back and expected high MSA's that would never be used. Some company's who are doing these MSA proposals are insuring them so if Medicare came back and stated the MSA was not large enough then the IW would not be liable. Injured workers can also request to manage their own MSA.

You can research online and talk to your attorney about all of this and do what you feel comfortable with.

If you are not having treatment request denials with your work comp case and are happy with it then you can leave your medical open.

Best to you.


RE: Medical set-aside inquiries - 1171 - 09-04-2019

(09-02-2019, 06:50 PM)Andy1689 Wrote:
(09-02-2019, 05:56 PM)1171 Wrote: FYI:
If the set aside amount is adequate, you’ll never get to a point where you need medicare; medicare is just a contingency when there is a set aside.

The set aside amount is not adequate, and when I get older my situation will get worse, I might need a surgery or go to the nursing home.... I’m so confused with Medicare and Medicare with AARP. I asked my current Medicare with AARP insurance company, the rep told me they will cover 100% after set aside money exhausted, but I was told by CMS I need to report to Medicare which’s only covered 80%. Don’t know who should I trust, if I need to pay 20% out of my pocket and I will reject the settlement.

is that your determination or CMS?
if you have separate coverage that kicks in to supplement medicare then you will have only minor payments. if CMS has determined the set aside amount as inadequate, then they could deny payments when the under- funded set aside is exhausted. (CMS requires their own review of the setaside amount before they will agree to back stop coverage of you comp injury)
you should review the information on the CMS site
https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Overview.html