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WCMSA--Will I need to establish one?
#1
Hello--I have been scouring the web to perhaps find a situation similar to mine so I may have a better idea of how my claim will conclude. Little luck so far, so here's the data, followed by my questions:

I'm a medically retired CA State employee, safety classification with a presumptive injury. I am unrepresented.

PD Rating 90%, (753.25 weeks), weekly rate $310.50 as per a +15% situation, future medical care is necessary. SCIF and the employer do not dispute the findings of the QME. LP will commence 4-16-2028 at the initial weekly rate of $231.92. I have never worked in Social Security-covered employment, am not eligible for SS Disability (according to the SSA), and therefore do not qualify for Medicare until the normal enrollment age of 65. I do have medical coverage for non-WC issues through my former employer's group health plan.

The DEU performed PD and LP commutation calculations in March. I used the Excel templates online and came up with the same numbers for the PD commutation, but my numbers for the PV of the LP commutation were some $33,000 less than the DEU's numbers. How is the Present Value of the LP calculated then? If I understand Baker vs. WCAB correctly, there will be SAWW COLA increases beginning January 1, 2029. How are these applied to determining the FV of the LP? I have since asked SCIF for a C&R, and they are now working on figures for a proposal to settle my claim.

Other questions:

How is my life expectancy calculated? Is it simply with the CDC Decennial Life Tables? If so, the LP would be calculated to the year 2043?

If this is the case, is the FV of the LP calculated for the time period 4-16-2028 to sometime in 2043?

I know a C&R will address future medical care. I do not meet the thresholds for CMS to review a WCMSA. (12 years until I am Medicare eligible, settlement amount > $250,000). Do any monies identified for future medical care still need to be set aside? If so, do I use these monies for WC issues right away, or do I wait until age 65 to use them for my injury?

My group health plan has told me they will cover medical needs for my injury after the claim is settled. Their philosophy is once the claim is closed, there is no more WC claim, and therefore nothing to charge expenses to.

I posed this question to Medicare, and they referred me to the SSA saying they will make the final determination for Medicare eligibility. I called the SSA, and they indicated that since I am not SSD eligible, and it will be 12 years until I can enroll in Medicare, that the set-aside question is a non-issue.

I also asked my Claims Adjuster these questions, and he referred me to the I&A Officer at the local DEU. She told me that ALL future medical monies need to be reviewed by CMS, but she included links in her message to the CMS website which directly contradicted her. So what is the truth?

Thanks for any information.


 
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#2
I'm not sure why you are trying to work a commutation as that process only applies to awards for periodic disability payments and not a compromise and release. In any event i do not have enough information to critique your calculations. the DWC spreadsheets predate the COLA provisions.
for complex disability calculations you may want to use an on-line calculator.
here are a couple (but I cannot vouch for their accuracy):
http://www.pdrater.com/original-calculators/
https://ww3.workcompcentral.com/calculator

according to the CMS guideline manual a Medicare Set-aside Agreement is not a legal requirement.
by following the CMS pre-settlement review process you would avoid having CMS take credit for your whole settlement against any future medicare claims rather then just the medical portion of the settlement.

neither a claims adjuster nor the I&A officer speak for CMS and are not an expert in CMS medicare set aside rules; let information from CMS be your guide as far as set asides go.

workers compensation life expectancy tables can be found at the bottom of the page here:
http://www.dir.ca.gov/osip/pubandforms.htm
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.
 
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#3
I recommend deleting all information that identifies you and your claim such as exact date of injury (year of injury is o.k.) date of birth etc. This is for your own protection as this is a public website.

You can edit your post anytime by clicking edit button.
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.
 
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#4
(05-29-2015, 11:23 AM)1171 Wrote: I'm not sure why you are trying to work a commutation as that process only applies to awards for periodic disability payments and not a compromise and release. In any event i do not have enough information to critique your calculations. the DWC spreadsheets predate the COLA provisions.
for complex disability calculations you may want to use an on-line calculator.
here are a couple (but I cannot vouch for their accuracy):
http://www.pdrater.com/original-calculators/
https://ww3.workcompcentral.com/calculator

according to the CMS guideline manual a Medicare Set-aside Agreement is not a legal requirement.
by following the CMS pre-settlement review process you would avoid having CMS take credit for your whole settlement against any future medicare claims rather then just the medical portion of the settlement.

neither a claims adjuster nor the I&A officer speak for CMS and are not an expert in CMS medicare set aside rules; let information from CMS be your guide as far as set asides go.

workers compensation life expectancy tables can be found at the bottom of the page here:
http://www.dir.ca.gov/osip/pubandforms.htm

Thanks for the response. I do understand there is a difference between Commutation and the C&R. I guess a better question to ask is, Are the amounts for C&R PD and LP the same or close to the amounts of totally commuted PD and LP?

You are correct about the calculators you referenced. They both produce figures very different from the DEU, and each other, using all the same inputs.

Thanks also for confirming my impression about CMS. There are three CMS publications which all say I do not meet the threshold for review.
 
Reply
#5
the only requirement for a settlement amount is that it be "adequate" as determined by the WCAB's review.
a commutation is required by law to allow 3% for interest saved.
there is no discount rate specified for a settlement.
a settlement generally uses a standard present value calculation as opposed to a commuted value.
I would say that many carriers use a much higher discount rate then 3% for valuing a C&R.

P.S. the carrier is not required to offer you a settlement and many uninsured/self-insured public agencies are hesitant to do so.
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.
 
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