Louisiana Worker's Compensation - Help For Injured Louisiana Workers

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  1. #1
    Join Date
    May 2007
    Posts
    408

    Default Understanding the Medicare Set-Aside

    After 4+ years it looks like WC is getting ready to settle. I am currently drawing WC and SSDI at the same time with no offsets. I am not signed up for Medicare B because I am on my Wives Insurance and my Wives Insurance is Primary on me. My wives company said it would not be beneficial to me to pay for Medicare B and the Social Security Admins. said the same and gave me a waiver meaning when my wife retires or if she loses her job I would not be penalized for not having signed up for Medicare part B.
    Okay, Here is my Question' How do I do a Medical set aside when I am currently on my wives Insurance instead of Medicare B? How do you do Future Medical set Asides under my circumstances? I suffer from a Back Injury in which I have a Titanium Cage, plates and screws in the Thoracic part of my spine(T12 corpectomy). The surgery was not successful as far as pain goes. I suffer from moderate to severe chronic back pain, nerve pain and scar tissue pain. I am on a 25 mcg/per hour Fentanyl patch, Lortab 10, Lyrica, Celebrex and Ambien. I change Fentanyl patches every 2 days and take 3 lortab 10/500s a day, 75 mg of Lyrica twice a day, 200 mg of celebrex daily and 10 mg of ambien at bedtime. I also have the Facet injections for pain relief. I visit pain management every month. My situation will not get better; It is what it is. WC pays for all of it currently but eventually my wives Insurance will be responsible. Any Help or Knowledge on this subject would br GREATLY APPRECIATED.
    Thanks in Advance.

  2. #2
    Join Date
    Nov 2006
    Location
    Ohio
    Posts
    324

    Default Re: Question about Medicare Set-Aside

    Hello Smackman

    Do you pay like a co-pay for being on wife's insurance?

    Are you settling your claim with an attorney for workers comp involved?

    It is my understanding that Medicare and the set-aside program is insisting the claimant's of workers' comp that are settling their claims open a different account to have a certain amount of monies into this account for payment of your medical bills/medication that are only related to your work comp claim and you the claimant are to keep records (my understanding a very good detailed accounting of all monies paid towards the allowed conditions in the claim out of that particular account) let me give an example if I may.

    Your bwc settlement is for $100,000.00 on the BWC settlement app you would have total settlement amount of $100,000.00; Indeminity: 80,000.00; Prescriptions: $5,000.00; MEDICAL BILLS: $15,000.00.

    It would be to the claimant's best interest if Medicare is a possibility in the near future to have that $20,000.00 (Rx and Med bills) into a separate account and every time you have an Rx filled or payment of medical bills i.e. doctor's office visit, x-rays etc, (only related to work comp injuries) pay the payee out of this account, keep all receipts and cancelled checks our bank statements for later use.

    Once the claimant has deleted all funds out of this set-aside account, then and only then will medicare start paying for the workers' comp injuries...you will have to submit the necessary paperwork to medicare to show that the $20,000.00 was used only for work comp injuries.

    From experience, I know that this Medicare Set-Aside program is taking this seriously and from experience, they will be auditing this program and the claimant that are having to deligate monies to the set aside program.

    If I am wrong some one please correct me but from our office's experience this is what has to be done...

    Now, how often they will audit we don't know, how long it will take once work comp settlement for set-aside is gone will it take medicare to start picking up the medical expenses....

    I hope this helps...


    Quote Quoting smackman View Post
    After 4+ years it looks like WC is getting ready to settle. I am currently drawing WC and SSDI at the same time with no offsets. I am not signed up for Medicare B because I am on my Wives Insurance and my Wives Insurance is Primary on me. My wives company said it would not be beneficial to me to pay for Medicare B and the Social Security Admins. said the same and gave me a waiver meaning when my wife retires or if she loses her job I would not be penalized for not having signed up for Medicare part B.
    Okay, Here is my Question' How do I do a Medical set aside when I am currently on my wives Insurance instead of Medicare B? How do you do Future Medical set Asides under my circumstances? I suffer from a Back Injury in which I have a Titanium Cage, plates and screws in the Thoracic part of my spine(T12 corpectomy). The surgery was not successful as far as pain goes. I suffer from moderate to severe chronic back pain, nerve pain and scar tissue pain. I am on a 25 mcg/per hour Fentanyl patch, Lortab 10, Lyrica, Celebrex and Ambien. I change Fentanyl patches every 2 days and take 3 lortab 10/500s a day, 75 mg of Lyrica twice a day, 200 mg of celebrex daily and 10 mg of ambien at bedtime. I also have the Facet injections for pain relief. I visit pain management every month. My situation will not get better; It is what it is. WC pays for all of it currently but eventually my wives Insurance will be responsible. Any Help or Knowledge on this subject would br GREATLY APPRECIATED.
    Thanks in Advance.
    Beth, Legal Assistant
    Wife and Mother of injured workers

  3. #3
    Join Date
    May 2007
    Posts
    408

    Default Re: Question about Medicare Set-Aside

    Quote Quoting whatamess View Post
    Hello Smackman

    Do you pay like a co-pay for being on wife's insurance?

    Are you settling your claim with an attorney for workers comp involved?

    It is my understanding that Medicare and the set-aside program is insisting the claimant's of workers' comp that are settling their claims open a different account to have a certain amount of monies into this account for payment of your medical bills/medication that are only related to your work comp claim and you the claimant are to keep records (my understanding a very good detailed accounting of all monies paid towards the allowed conditions in the claim out of that particular account) let me give an example if I may.

    Your bwc settlement is for $100,000.00 on the BWC settlement app you would have total settlement amount of $100,000.00; Indeminity: 80,000.00; Prescriptions: $5,000.00; MEDICAL BILLS: $15,000.00.

    It would be to the claimant's best interest if Medicare is a possibility in the near future to have that $20,000.00 (Rx and Med bills) into a separate account and every time you have an Rx filled or payment of medical bills i.e. doctor's office visit, x-rays etc, (only related to work comp injuries) pay the payee out of this account, keep all receipts and cancelled checks our bank statements for later use.

    Once the claimant has deleted all funds out of this set-aside account, then and only then will medicare start paying for the workers' comp injuries...you will have to submit the necessary paperwork to medicare to show that the $20,000.00 was used only for work comp injuries.

    From experience, I know that this Medicare Set-Aside program is taking this seriously and from experience, they will be auditing this program and the claimant that are having to deligate monies to the set aside program.

    If I am wrong some one please correct me but from our office's experience this is what has to be done...

    Now, how often they will audit we don't know, how long it will take once work comp settlement for set-aside is gone will it take medicare to start picking up the medical expenses....

    I hope this helps...
    Do you pay like a co-pay for being on wife's insurance?
    YES My wives insurance thru her company does have co-pay for doctor visits, prescription drugs, etc. Example it cost 20 dollars for a Doctor in her PPO, 15 dollars for prescription drugs, etc. etc.


    Are you settling your claim with an attorney for workers comp involved?
    YES This is the same Lawyer who helped me with my SSDI Claim.

  4. #4
    Join Date
    Nov 2006
    Location
    Ohio
    Posts
    324

    Default Re: Question about Medicare Set-Aside

    Thanks for answering,

    Did your attorney explain to you the need to set up the medicare set-aside account?

    Do you have a lot of medical expenses regarding your work comp injuries?


    I know we are preaching this to our clients who maybe or close to receiving Medicare benefits to do this. I just don't know the ramifications if they don't.

    I can give you an experience example...a claimant was settling claim, medicare was accidently billed and paid for medical expenses that were work comp related.....we have been put on notice that we have to collect said dollar amount out of upcoming settlement. So, we are taking this seriously.....

    Be sure to ask work comp attorney the what ifs...
    Beth, Legal Assistant
    Wife and Mother of injured workers

  5. #5
    Join Date
    Dec 2006
    Posts
    2,165

    Default Re: Question about Medicare Set-Aside

    Smackman, are you not having off-sets deducted from your SSDI checks because your combined WC monthly benefits plus your SSDI is within the 80% of your highest average monthly income?

    OR, off-sets DO apply, but SSDI has not yet calculated what they will be?

  6. #6
    Join Date
    May 2007
    Posts
    408

    Default Re: Question about Medicare Set-Aside

    Quote Quoting Charles Stevens View Post
    Smackman, are you not having off-sets deducted from your SSDI checks because your combined WC monthly benefits plus your SSDI is within the 80% of your highest average monthly income?

    OR, off-sets DO apply, but SSDI has not yet calculated what they will be?
    My SSDI AND WC combined is LESS THAN THE 80% rule. The Awards letter I received from SSDI stated that there would be no offset. By my figures I am 150 dollars a month away from a offset using my best 5 years as a average with Social Security.

  7. #7
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,017

    Default Re: Question about Medicare Set-Aside

    ''WC pays for all of it currently but eventually my wives Insurance will be responsible.''

    I don't know where you came up with that information, But your wifes insurance will Never be liable for the costs of your work related injury. Either your WCMSA or Medicare will pay, but NOT another IC.

    ''My SSDI AND WC combined is LESS THAN THE 80% rule. The Awards letter I received from SSDI stated that there would be no offset. By my figures I am 150 dollars a month away from a offset using my best 5 years as a average with Social Security. ''

    Then the reason you are not subject to an offset is because your SSA maximum award is not enough to make an offset necessary. When you take SSDI benefits it is the same as taking an "early retirement''...it is not ususual not to have an offset due to your 'retirement' benefit not being sufficient for you to reach the 80% rule used for SSDI.
    While they (SSA) use the highest average wage during the last 5 yr (if necessary), the retirement benefits are based on 40 points...or highest earning quarters worked where there were qualifying wages reported. (Usually...the last 10 years as typically those are the highest earning years) Sometimes it depends a great deal at which point you make application as SSA uses previous quarters to calculate benefits.

  8. #8
    Join Date
    Dec 2006
    Posts
    2,165

    Default Re: Question about Medicare Set-Aside

    As Whatamess pointed out, one must be VERY careful about HOW the set-aside funds are utilized.

    If you have a set-aside, it MUST be placed in an interest-bearing account, and it MUST be either administered by a third-party Adminstrator OR, it can be "self-administered". CMS needs to be advised WHO is going to administer the set-aside.

    The administrator MUST make YEARLY ACCOUNTINGS to CMS regarding the funds that were withdrawn from the set-aside account for treatment costs of the industrial injury.

    IF the set-aside is NOT set up in the settlement PER CMS's DETERMINATION of ADEQUATE FUNDING OF THE SET-ASIDE, ALL parties are at risk of Medicare's "wrath". For the IW, this means they could LOSE their Medicare benefits. For the attorneys, Medicare may demand double or TREBLE damages, and have a malpratice lawsuit by the IW filed against them.

    IF Medicare has paid even ONE CENT for treatment for the idustrial injury PRIOR to settling, Medicare will ALSO want ANY and ALL "Conditional payments" made by Medicare to be REIMBURSED TO THEM and SPECIFIED in the settlement papers, and you better make DARN SURE that the IC REIIMBURSES MEDICARE for those "conditional payments".

    Otherwise, Medicare WILL expect the IW to PAY MEDICARE BACK, and the IW can NOT use the funds from the Set-aside to repay Medicare's conditional payments.

    The reality these days is, Medicare and OTHER HEALTH INSURANCE COMPANIES, i.e. Spouse's Group Health Care, are VERY TIRED of "picking up the tab" for WORK-RELATED INJURIES and having the "COST-SHIFTING" that has occurred when Work Comp "settles" and "relieves themselves" from LIABILITY for future medical care ....

    So, you and your attorney better read the FINE PRINT and the "EXCLUSIONS OF COVERAGE" if you think your spouse's medical insurance is going to cover YOUR industrial injury after you settle and exhaust the set-aside....

  9. #9
    Join Date
    Nov 2006
    Location
    Ohio
    Posts
    324

    Default Re: Question about Medicare Set-Aside

    it is all very confusing...I am curious as to why the OP's attorney has not explained this in detail (or he might have it just isn't expressed in OP).

    We handle both work comp and ssd benefits and our attorney is very concerned about this new set aside program and the "enforcement" They can recoup from the attorney for the claimant's mistakes (just not sure how yet)....

    I know the one we are working on right now which all parties are "fitting" over is a settlement over $250,000.00 and this settlement obviously has to be pre-approved...we just got notification that now since CMS has received all necessary paperwork it will take them 5-6 on getting the final approval.....I am concerned this will hurt the claimant's over all settlement with the BWC...but who knows....

    I believe that the injured workers/claimants need to read and research as much information as possible..don't count on what one person or facility says...know ALL facts before signing anything.

    Good luck, I am still trying to figure it out and not sure I ever will

    Beth
    Beth, Legal Assistant
    Wife and Mother of injured workers

  10. #10
    Join Date
    May 2007
    Posts
    408

    Default Re: Question about Medicare Set-Aside

    Quote Quoting BvIA View Post
    ''WC pays for all of it currently but eventually my wives Insurance will be responsible.''

    I don't know where you came up with that information, But your wifes insurance will Never be liable for the costs of your work related injury. Either your WCMSA or Medicare will pay, but NOT another IC.

    ''My SSDI AND WC combined is LESS THAN THE 80% rule. The Awards letter I received from SSDI stated that there would be no offset. By my figures I am 150 dollars a month away from a offset using my best 5 years as a average with Social Security. ''

    Then the reason you are not subject to an offset is because your SSA maximum award is not enough to make an offset necessary. When you take SSDI benefits it is the same as taking an "early retirement''...it is not ususual not to have an offset due to your 'retirement' benefit not being sufficient for you to reach the 80% rule used for SSDI.
    While they (SSA) use the highest average wage during the last 5 yr (if necessary), the retirement benefits are based on 40 points...or highest earning quarters worked where there were qualifying wages reported. (Usually...the last 10 years as typically those are the highest earning years) Sometimes it depends a great deal at which point you make application as SSA uses previous quarters to calculate benefits.
    My Wives insurance carrier told her that they would assume responsablity for my medical claims when I settled with WC. I did not pull that answer out of the air. This came from my wives Human Resource department after Human Resources checked it out with my wives Insurance carrier. My Lawyer has not addressed this situation because I have not been designated as MMI BUT my WC adjustor is trying as we speak to get this rolling. He is talking to my pain management Doctor today and he says he will make a appointment with my spinal surgeon in a effort to get a MMI report. This is all preliminary; I am just trying hard to be as prepared as possible in case my Lawyer is not prepared. We have not even discussed this settlemnt because there has been no attempt from the IC to settle this but my claim adjuster has let me know that he is pushing for this MMI from my Doctors. When my Lawyer gets the letter that they want to settle then he will roll. I am just trying to take care of self and be in the know when I sit down and discuss this settlement with him. Medicare has not paid one red cent of my injury.

    As far as the offset I totally understand why I was not offset. I draw Maximum from SSDI and WC as we speak. Its all about how much you made and also how much you draw from your State WC Claim.

    I do appreciate all the info.

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