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MSA/C & R Clarification Please
#1
Thanks so much for this forum!

Work injury (spine) 20+ years ago, California. Settled by Stips, 20+ years ago. All that is left is Future Medical and I am ready to C & R it. All treatment in the last 19 years has been chiropractic. Never any surgeries and none expected. No attorney.

I've agreed w/IC to settle for $10,000. IC says there is no need for an MSA in order to settle this claim as I am not currently a Medicare beneficiary. However, I am 63. I asked the I & A Officer who at first said, that's right, not necessary, but then after thinking about it, said "Actually I'm not sure, because of your age."

1) I would like to sign C & R now and this is my main issue left. Is an MSA necessary? (I'm pretty sure it isn't, but I would like to do this right.)

2) Do I need to insist on any language in regards to Medicare's interests? If so, how to state it and where in the C & R would it go?

3) What is the worst case scenario if the language of this C & R is wrong and the WC Judge doesn't catch it? If it ends up that the C & R wasn't done correctly in the eyes of CMS down the line after I've spent the $$ on my spine, is $10,000 the maximum amount they could expect me to cover before they begin paying Medicare benefits for my spinal issues? Can they go back into Stipped amounts paid to me 20 years ago? PD was $30,000. (I'm pretty sure they can't, but since I am asking questions here...)

The more I read about this on the CMS/Medicare sites and WC forums, and after talking to IC and I & A, the more confused I have become. Any help would be greatly appreciated. Thank you kindly.
 
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#2
It's never "necessary"; you just run the risk of having CMS disallow future Medicare treatment for the work injury if CMS doesn't pre-approve a base amount.
The review criteria are 62 yrs 6 mths and $250k settlement.
https://www.cms.gov/Medicare/Coordinatio...on-2_6.pdf
There is no mandatory language. But you can quote the criteria That excludes the CMS review thresholds for your settlement. Just because it doesn't meet the review threshold doesn't mean they will automatically cover your work injury treatment. You still can't pocket the settlement $$ and expect them to cover the comp treatment. The whole point of an WCMSA is to stop the cost shifting from comp to Medicare. Undoubtedly your claim has been reported to CMS and will flag when bills for the com injury are sent to them for payment.
Yes, without pre-approval CMS can refuse coverage until entire settlement amount has been accounted for in cmp injury medical treatment.
Set asides only deal with future medical not past payments.
You can also contact CMS for help
https://www.cms.gov/Medicare/Coordinatio...ation.html

It may be wise to keep a record of the comp treatment amounts you pay for after the settlement.

I am not an expert in when and how CMS applies its rules.
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
Thank you. I have been to both of those links before and unfortunately they still leave things unclear.

I do not plan to pocket the $10K I will get for future medical. I do plan on having a separate account for it and using it on chiropractic treatment for my spine, and will keep receipts. I'm a very good record-keeper. I'm not worried about that part.

When you say, "Yes, without pre-approval CMS can refuse coverage until entire settlement amount has been accounted for in cmp injury medical treatment" I am further confused. Do you mean the $10,000 for future medical, or everything they have paid for this WC case; TD, VRMA, PD, prior med and Future med? All together it is less than a total of $250,000 so it is my understanding they do not want to see requests for pre-approval.

I'm sorry to sound so dim on this but the MSA stuff has me completely baffled. Thank you very much.
 
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#4
you are not dim. this stuff is crazy complex.
these posts are here for others with similar questions so I often include information and provide a broader response to help those who may not be in the exact same situation as you.
it's obvious you want to do it correctly.
TD, VRMA, PD, prior med are all benefits not settlement. the $10K C&R is a settlement. it is what the WCMSA is for.
it is the limit of CMS secondary payor interest. comp monies you may have received in the past are not in danger of being double billed or double paid and they are outside of the scope of your future needs.
you are correct.
while you may meet the age threshold you DO NOT meet the amount limit for pre-approval.
these thresholds have varied doing the course of the many years of WCMSA guidelines. they help CMS set its workload. obviously CMS cannot review every work comp settlement in the US. but they want to capture the larger most impacted settlement population. the secondary payor provisions of the Medicare Act apply to every dollar not just those at $250K. those that have pre-approval have a stronger argument against any future coverage exclusion then those without it.
the secondary payor provisions have been in effect for many years. CMS just did not have the means or inclination to enforce it until medical costs and their settlement value skyrocketed in the past 25-30 yrs.
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
Thank you very much; that really helps to clarify. I appreciate you taking the time and breaking it down for me, along with a little history lesson, and hope it is helpful to others too. I have been reading and stressing about this for far too long. Many thanks.
 
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#6
Be well.
Thankx for the post.
I enjoyed trying to give a good answer.
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
You succeeded. Thanks again.
 
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