Page 1 of 3 123 LastLast
Results 1 to 10 of 22
  1. #1
    Join Date
    Apr 2007
    Posts
    186

    Default Does Anyone Already Have a Medicare Set Aside?

    My workers compensation claim was made in the State of: ILLINOIS.
    I settled my work comp case in August, 2008 for my back injuries. Last friday I got a letter from CMS stating that my medicare set aside should be funded for $230,000 with 25,000 down and 7,800 per year for 26 years. The IC has until March 15th to either agree to that figure or reject it and keep my medical open for life which was in my settlement closing papers. The IC had submitted a figure of $97,000 for the set a side.
    I have to administer these funds as part of the agreement so I was wondering how do I go about paying for the monthly doctor visit and my drugs. Do I have to tell them this is a medicare set aside and will I get a special discount for billing purposes for both the doctor and the drugs? I have no idea how to handle that part of the case. The actual paying of the bills every time I need service. Are we entitled to discounted pricing like medicare would receive? I am just curious.Thanks

    Mike Walsh

  2. #2
    Join Date
    Sep 2007
    Posts
    152

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    Hello Mike I personally am so disappointed to hear the amounts of your settlement . How cruel , inhuman and greedy can the IC & ER be? I am so very sad for you , me and us other injured workers . I wish more would be forthcoming with actual amounts , i know i will be when mine is settled . Poverty level income was around 14 K a year last i saw , and considerably more if you wanted to sponsor a person from another country , a bit of a double standard i would think . What a sad state that this is allowed . Your's and all of our thanks for being injured at work . Truly this is insult to injury . Apologies that i do not know the specifics to your question . Mad Mart

  3. #3
    Join Date
    Apr 2007
    Posts
    186

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    The amount of $230,000 is for my medicare set aside only. I settled my work comp case for $222,000 less 20% to my attorney. The IC agreed to keep my medical open until they got a figure from CMS for a set aside. Now the IC has 60 days to decide if they will fund the set aside with $25,000 down and 7800.00 per year for 26 years or keep my medical open for my life. My drugs alone run between 700-1000 per month. I am just not sure how I deal with the pharmacy and doctors with my set aside money. Am I entitled to a discount for drugs and doctor visits being a medicare patient? I guess I will have to call medicare and find out how much the doctor is allowed to charge for the monthly visit to the pain doctor. All new to me.

  4. #4
    Join Date
    May 2007
    Location
    Calif
    Posts
    483

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    Maw: from what I have found your CMS paperwork will tell you whether or not your medical expenses are to be paid at the WC agreed rate.

    I just "googled" how to administer a MSA and found a very good article that spells it all out, provides reference to the CMS forms, tax conseqences etc....uncertain if I can post it here or not....

    so I will send you a pm with the link......hope this helps you and answers a lot of your questions......the link I found does not solicit your business rather it explains the ins and outs.....

    RW.....

  5. #5
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    Mike...

    While the approval letter you received from CMS outlines the anticipated dollars for your care over the next 'life expectancy' years...those are NOT figures that are limited to your expenditure.

    When you are provided treatment, you notify the doctor that the bills are to be sent directly to you as though you were a 'private pay' patient.
    AT the "Medicare approved charges''...for the procedures you receive.
    Medicare has 'approved fees/charges' for all services, and there are exclusions as well. So NOT ALL services you may receive are to be paid from the WCMSA. AND, you cannot pay the co-pays and deductibles, OR any Medicare gap/HMO/PFF coverages as may be available to you because you are Medicare eligible.

    So, no there are no 'discounts', just the Medicare fees should be billed.
    Also, you are charged with auditing that account/setaside on an annual basis to determine that ONLY Medicare approved charges are paid from the setaside.

    There is information here on taxes and other issues http://www.cms.hhs.gov/WorkersCompAg.../71105Memo.pdf (income generated by the setaside deposit, is to be included in the account, and taxes can be paid from those funds...)

    There are lots of companys that administer WCMSA accounts, here is one that you might get an overview of their services...http://www.gouldandlamb.com/
    These vendors administer, account to CMS, handle all the billing, and provide for discounted drug services. Among other services. THere are fees for this, and should be included in any C&R to your medical benefits. The fees cannot be paid from the setaside funds.

    Here is information from CMS on the administration of a WCMSA.
    http://www.cms.hhs.gov/WorkersCompAg....asp#TopOfPage


    There is a LOT of information you need to be aware of before you accept any settlement agreement that inlcudes a WCMSA...1) Is there money additional to the setaside account to cover your out of pocket expense. There WILL be costs you will have to pay that cannot come from the setaside account.
    2) The AA is entitled to a fee on the C&R of the medical to your claim ..where is the money coming from for the AA fee?
    3) If necessary for an outside WCMSA vendor/administrator, where is that money to come from... the IW should not be required to pay for set up costs, or administer the account themselves.

    You should also consider a Structured Settlement to fund the WCMSA...an annuity would be purchased for this, and not through the WC carrier. If you do this outside the IC, there would be an 'estate' value to your account. Otherwise any money remaining in the setaside when you die could revert to the ER/IC. Structure inforamtion is here...https://www.cms.hhs.gov/WorkersCompA...uredwcmsas.pdf

    Before you finally agree to any settlement of your medical benefits be SURE you fully understand the requirements and responsibilities of this account and determine IF you are willing to undertake the duties involved.
    Your AA is doing you a disservice if s/he is not fully advising you on the details of this settlement.

    You may not be dealing with any of these issues as CMS is demanding over double the amount agreed to previously...and the IC is under no obligation to accept or fund this WCMSA.

    Hello Mike I personally am so disappointed to hear the amounts of your settlement . How cruel , inhuman and greedy can the IC & ER be? I am so very sad for you , me and us other injured workers . I wish more would be forthcoming with actual amounts ,
    While many IW's may feel their settlements should be in the 100's of thousands, or even a Million or more, each situation is unique unto itself, and only the IW involved in the claim can make a determination as to what they will accept in a settlement.

    Where the PD indemnity is pretty much set by law in most circumstances, the only negotiating tool left is the future medical portion of the claim. Where the IW is Medicare eligible, and CMS in involved, CMS makes the decision for us...and that figure is not negotiable, or permitted to be paid in 'todays dollars'.
    This settlement may be perfectly adequate and 'fair' to the circumstance surrounding this claim.

  6. #6
    Join Date
    May 2007
    Location
    Calif
    Posts
    483

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    How does one find out what the "Medicare Approved Charges" are?

    I understand Calif has an "Official Medical Fee Schedule" and it is referenced by the DWC however for the most part it is in greek and I would assume that the fee schedule is based on ICD-9/CPT codes with modifiers and subject to continual change.

    Can an IW request a copy of the schedule directly from CMS? or must they obtain it from another source? What source?

    I also understand that a physician can refuse to accept the Medicare schedule, so if this were to occur; How does one know what the reasonable and customary charge are for the particular service or modality.?

    Just curious......RW
    Last edited by roofinfool; 01-09-2009 at 08:02 AM.

  7. #7
    Join Date
    Apr 2007
    Posts
    186

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    My attorney was not involved at all in the medicare set aside. The IC hired an outside company called Protocol LLC to handle the set aside and the submission to CMS. In the package I got from CMS itt says my WCMSA is funded as a structured settlement. They have an initial deposit amount and subsequent deposits for the next 26 years. In my work comp settlement contract I agreed to act as the administrator of my WCMSA funds. Also I had to agree that upon my death the funds would revert to the IC. CMS gave me the paperwork already for the annual accounting expenditures and the instructions for me on what I have to do each year and how to fill out the form. I have to wait 60 days now to see if the IC will fund this set aside or reject it and keep my medical open for life as they agreed to in my settlement contract. With my drugs alone running almost 1000 per month I think it is to their advantage to let CMS take over with the set aside.

  8. #8
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    With my drugs alone running almost 1000 per month I think it is to their advantage to let CMS take over with the set aside.
    CMS does not 'take over' with the WCMSA... YOU 'take over', The setaside account is tantamount your paying out of your pocket...Medicare will not step in to pick up the costs of treatment to anything contained in the proposal approved by CMS until you prove all the money, including interest has been fully exhausted.

    As your seaside is funded by an structure, each year when you spend all the money is the setaside, Medicare will begin to pay... then when the next deposit is made, you reimburse Medicare for any advance payments that have been made for your care.

    "Medicare approved charges'' are pre set, and each year CMS/Medicare provides all Medicare eligible people a guidebook with an explanation of benefits, as there are some changes every year.
    There are also limits to some of what Medicare will cover... eg PT, Chiro, and some medications are not covered, or not fully covered.
    It is very important to audit the bills, and ensure you are not paying from the setaside account ANY fees that Medicare is not 'normally responsible for'.

    I also understand that a physician can refuse to accept the Medicare schedule, so if this were to occur; How does one know what the reasonable and customary charge are for the particular service or modality.?
    You don't treat with that doctor. Or you don't pay out of the setaside account....for any charges above what Medicare accepts.
    Providers don't have to accept Medicare patients...and those doctors are probably not the ones you want to treat with, as the billing would be near impossible to decipher.

    I understand Calif has an "Official Medical Fee Schedule" and it is referenced by the DWC however for the most part it is in greek and I would assume that the fee schedule is based on ICD-9/CPT codes with modifiers and subject to continual change.
    Calif OMFS has nothing to do with Medicare 'approved charges'. In fact the OMFS is about 120% of Medicare approved fee schedule.

    eg. Doctor bills $100 usual & customary... Medicare approved fee is $68.00, for the service provided..the is a 20% co-pay you pay out of your pocket. That co-pay cannot come from the setaside account.

    If you are hospitalized, you pay $195/day for days 1 through 18, plus 20% of the Medicare approved charges...
    X-rays, radiology... 20% of Medicare approved charges.
    The list goes on and on, and I don't have my Medicare book in front of me now... but as you can see, 'selling' your WC medical is not always what is appears. In this case, the ER/IC is not providing a custodial account, and appears to be letting the IW pay out of pocket for the co-pays and deductibles, as well as maintain the setaside account. The IC is getting out of administering the claim where medical treatment is the benefit being provided...pretty good deal for the IC...(?)
    This 'settlement' is obviously in favor of the IC... NOT the IW.

    IF this is to be settled and the WCMSA funded by a structure...there should be an annuity purchased by the ER/IC, in the name of the IW, and a 'estate' value would result if the IW dies prematurely, and there is residual money in the account.

    If the IW is not fully indemnified in a C&R for the medical treatment to this injury... WHY would anyone accept this settlement?
    1) IW administers the medical portion of the claim...
    2) IW audits and reports to CMS
    3) IW...PAYS out of pocket for costs Medicare is not 'normally responsible for'...

    Bottom line in this claim...IMHO, the IW is NOT being offered a settlement that is in his/her best interests...

    BTW...the monthly medication cost here are average 1000/1200 month...who is going to pick up the cost for medications here during the 'gap' period. There could be several months of $1200.00 out of pocket for medications...(?) The WC carrier is not about to step in and pay for 2, 3 or 4 months of meds this IW may not have the funds for. Here again, that money cannot be taken from the setaside account.

  9. #9
    Join Date
    Jan 2009
    Posts
    1

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    Mike,
    I fractured my spinal column in 4 places 2003, 4 major surgeries 18 screws and two plates later, I have joined the ranks of thee fully disabled. Today I recieved my WCMSA, what you will do is have it setup in a seperate interest bearing account(checking) and when you get your meds, doctor visits, anything that purtains to your WC injury simply write a check from that account and by all means we need to keep receipts. Then once a year we will fill out the forms with expenditures and receipts and send it in within 30 days following our WCMSA confirmation Date. My WCMSA was 97,ooo and change. Take Care good luck joseph

  10. #10
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Does Anyone Already Have a Medicare Set Aside?

    Joseph, doesn't sound like your best interests were served well in your settlement either....

    Keep in mind please... as I have said repeatedly... you can ONLY use the WCMSA money for Medicare approved charges... that Medicare would 'normally be responsible for'... that does NOT include your out of pocket share of costs...so yes... while it is very important to keep all of the records of provider billings...you should also be paying those bills with TWO checks...one from your personal account, and one from the WCMSA account. You'll find things much easier to account for at the end of the fiscal year.

    simply write a check from that account and by all means we need to keep receipts
    Oh but were it that 'simple'....

Similar Threads

  1. Medicare Set-Aside
    By trpette in forum New York
    Replies: 2
    Last Post: 10-28-2009, 05:16 PM
  2. Medicare Set Aside
    By maw19531 in forum Disability Benefits
    Replies: 11
    Last Post: 02-19-2009, 07:44 PM
  3. Medicare Set Aside
    By chattyqueen53 in forum Pennsylvania
    Replies: 4
    Last Post: 02-03-2009, 09:21 AM
  4. Medicare Set Aside
    By MAALYN in forum Disability Benefits
    Replies: 1
    Last Post: 12-26-2008, 11:36 AM
  5. Medicare
    By kelbail in forum Pennsylvania
    Replies: 1
    Last Post: 10-09-2008, 02:08 PM

Bookmarks

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
 


Find a Lawyer