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WCMSA
#1
I settled my wc case 2 years ago, with open medical for life... So far the medical has been a pain with constant denials, in which only took a phone call every month to get it approved.. Almost a year ago they wanted to do a wcmsa and I did however talk to my attorney and we felt lets see what they come up with.... Long behold when receiving a copy of the proposal wc ins low balled it and cms said no with a much higher amount.. Two meds were not listed and not enough dr visits and misc..... Anyways, sent it back with corrections and received the new proposal today.. The amount is higher but the amount of meds are decresed and still missing 2 meds.... Since a month ago they have ended medical coverage, reason they gave is I have not signed the proposal for the msa... 
Reasons why I wont go along with it..
 
 No mention of hip replacement needed, possible back surgeries...per noted by dr.
 The amount of meds is less than half of what i take, and 2 meds not even listed which are roughly $450 per month.
 I'm not even getting ssdi bennifits, but do have ins through the state which is not permanent..
 Plus when I settled there was no mention of a wcmsa in the agreement. Simply stated medical for life.

  My attorney has abandoned me, telling wc ins its ok to talk to me about everything and ignores my calls and letters.
  Am I legaly bound to sign the wcmsa, even though the agreement was for open medical..?  Maybee someone can steer me straight and advise me..............1171..?  Anybody..?
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#2
no, you don't have to sign.
the wcmsa is a settlement in every sense of the word. once it's done you have no recourse to the comp court for enforcement of your award of medical for life.
looks like you'll have to get ready to take them to court yourself.
every time there is a denial reply in writing that you request penalties for the delay in benefits..
it'll be up to you to decide when to file for court enforcement of the award.
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
Thanks 1171, it is as i thought..  The only reason for even considering them to do it was we were sick of every month they would deny all or at least one of my meds.. If the funds in the msa was more true to the price i may have been favored.. I personaly get flustered when talking But my wife on the other hand had a three way call between a wc judge and the adjuster a few months back over denials... I'm thinking it is time again..   Thanks again...
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#4
there is some hope however.
if CMS ever does approve an amount, it will commit them to pay for your injury treatment for anything in excess of that.
so you won't have to go without necessary care and they are probably easier to deal with then the comp carrier.
if you have an idea of what figure CMS will accept. it would be nice to let the judge know that during one of the 3 way conversations. if he sees a way out of the constant denials he can put some pressure on the carrier to make the whole case go away.
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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#5
Do you need a MSA if you are not receiving SSDI or Medicare?

It is my understanding this is money that is to be used instead of Medicare and it does not cover things like co-pays and deductibles. There are ways to structure the MSA with donut hole type coverage for out of pocket expenses as well as cover things that Medicare does not cover. I have never understood why a person cares how much their MSA settlement is...because it is basically giving these monies to Medicare, unless you can negotiate the out of pocket coverage (because you are using it instead of Medicare). I would like to get 1171's opinion on this and if things are left out of the MSA like a surgery, won't Medicare pay for the surgery?
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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#6
I think workers that want a settlement fear that a low MSA submission from the carrier has a high chance of rejection by CMS and therefore  more delays in getting treatment.
Yes, once the MSA is exhausted all injury treatment reverts to Medicare coverage for a those otherwise eligible.once CMS accepts the MSA amount it shouldn't matter to the worker whether it's " high" or "low".
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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#7
1171, many injured workers I believe have a misconception on what a MSA does and believe it helps them in some way monetarily when it is high. I have seen injured workers fight hard for high MSA's and I believe often times the more that is in the MSA the less the monetary settlement for the IW. The only way it is beneficial is if language in the MSA states there is monies for out of pocket expenses, but again those monies may just be taken from what the IW is paid in the settlement.

I remember helping an IW who had a LTD policy and is on SSDI. According to their LTD policy ANY income in a WC settlement is considered as income and the LTD company will just stop their payments and spread out what the C&R amount is over years...so basically it is a wash. Since the MSA does not cover out of pocket or deductibles the only one who has any gain from the MSA is Medicare.

Thank you for your response.
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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#8
those workers must somehow think that the only med they have for their claim is the MSA and then they'll be left without coverage.
I'm sure Medicare doesn't see an MSA necessarily as a "gain" but as a reduction in their secondary losses.
carriers were cost shifting to medicare for years with their low balled C&Rs and the set asides have made that a bit more difficult.
one fact that is often overlooked is that for CMS an MSA is optional. the only "enforcement" provision in the secondary payer act is one that allows CMS to hold the entire C&R amount as credit before providing care when there has been an unapproved settlement of treatment.
when the disability portion of a settlement is relatively small that's not much leverage and may not make the MSA process worthwhile for the worker.
it would be nice to hear some first hand experiences of those that settled without an MSA and are medicare eligible to see how strict CMS has been.
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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