Washington, DC Worker's Compensation - Help For Injured Washington, DC Workers

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  1. #1
    Join Date
    Jul 2010
    Posts
    150

    Default Medical Set Aside

    My workers compensation claim was made in the State of: DC

    I am a little confused about this. A medical set aside is monies allocated for future medical care, this part I understand. Heres what I don't, does every MSA have to be approved by Medicare? If not what are the factors that are involved that required a Medicare review? Is it based only on past cost for care of injury?

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Medical Set Aside

    There is a difference in a MediCAL setaside arrangement and a MediCARE setaside arrangement.
    CMS must review and approve a MediCARE setaside arrangement proposal if the triggers are met.
    MediCAL setaside doesn't have anything to do with CMS/Medicare.

    IF you are Medicare eligible within 30 months of any settlement that changes/closes the medical benefits/coverage in your comp claim, you must take the steps to protect Medicare interests.
    Medicare eligibility is determined by application for disability benefits, or being in the appeal process, or age/normal retirement.
    Is it based only on past cost for care of injury?
    MSA proposals are based on the past 2 years of medical treatment/costs you have received, and what the Dr reports say as anticipated medical needs in the future. FMC/Future Medical Care is a SWAG/Scientific Wild Ass Guess at best. However, there are MSA vendors as well as CMS who are quite astute at doing the calculations and projections.

    You shouldn't negotiate any FMC without consideration of money for services Medicare does not normally pay for. There could be significant out of pocket costs for you when the MSA money is exhausted.

    There is additional info at www.cms.gov and numerous threads on this board. Review the "Disability Benefits" board.

  3. #3
    Join Date
    Oct 2010
    Posts
    14

    Default Re: Medical Set Aside

    If I am on SSDI and will get Medicare in few month. Also receiving TTD. Now I am about to settle the case with Permanent partial disability and CMS approve Medical set aside. Who will manage this set aside account?
    Medicare - IC - IW? And what happens to it if none of the amount is used and PPD is ended?

  4. #4
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Medical Set Aside

    Medicare has no interest in the MSA, you or a professional MSA vendor/administrator can handle the setaide arrangement. THere is a cost for professional adm. IC's don't usually like to pay for that, and insist the IW self administer. Not necessarily an easy job. Not impossible though.

    The MSA and PPD benefits are not dependant upon one another. If the MSA money is never exhausted, it simply goes to your estate. You can't get the cash out any more... use to, but they changed that rule.

    There should be cash in the settlement for non Medicare covered services...that money is much more valuable to the IW in settlement than the MSA.

  5. #5
    Join Date
    Jul 2010
    Posts
    150

    Default Re: Medical Set Aside

    That site is insanely complicated. I read for about a hour...yikes. I really hope I don't have to deal with those issues. I think I am starting to see why it takes so damn long to get your case involving medicare approved. I picked up the discharge summery from my 5 week work hardening program today and I only made it to medium and my job is classified as very heavy, so it looks like I won't be doing that type of work again. I see my doc tomorrow morning and I am suppose to be MMI. i know I will get more info. then.

    From what I have been reading it looks like I could end up with a MSA with no medicare involvement? Does that happen or is it wishful thinking? I know you guys hear this all day but I really want these guys out of my life and I want to move on. Thanks again.

  6. #6
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Medical Set Aside

    I really want these guys out of my life and I want to move on.
    Therer is no guarantee of a cash settlement in WC.
    WC is about paying benefits, not settlemetns.
    Once you have a PD rating, a number of weeks "benefits" will be determined, Don't know exactly how DC defines that. But generally, a number of weeks continuing benefits at the weekly rate you are now being paid. After that... no more.
    Continued access to medical as necessary.
    YOu can't force a cash payment to settle the claim.

    You would only require a WCMSA/Medicare Setaside Arrangement IF you are Medicare eligible... there is no mandate for a mediCAL setaside arrangement. If you take a cash payment for future medical treatment, you do NOT have to have a seperate setaside arrangement, you can of course spend the cash any way you like...BUT, when you do become MediCARE eligible, you will have to prove you have exhausted that money before Medicare will pay benefits to this injury.

    badlanding... ARE you now Medicare eligible through age, disability, or application for SSDI/disability?
    That is what determines your potential need for a WC MSA.
    From what I have been reading it looks like I could end up with a MSA with no medicare involvement? Does that happen or is it wishful thinking?
    Depends on the dollar amount of benefits you have received during the claim. And the dollars in any cash settlement including atty fees.
    Try this site http://www.jjcelderlaw.com/SettlementProcessMSABull.htm
    and here http://www.cms.gov/WorkersCompAgency.../71105Memo.pdf

  7. #7
    Join Date
    Jul 2010
    Posts
    150

    Default Re: Medical Set Aside

    Those links helped a lot. I am 30 and i doubt i qualify for SSDI which I imagine you would have to have a pretty high disability rating to be considered. In a perfect world I would rather have whatever benifits I am entitled to paid over time because when it comes down to it a settlement is just that.....settlement which means you get less and the IC gets to keep more I think I have had about enough of that. Thanks again BVIA.

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

    Default Re: Medical Set Aside

    I am 30 and i doubt i qualify for SSDI which I imagine you would have to have a pretty high disability rating to be considered.
    Your PD rating to the work injury is NOT relative to the application or award of SSA/SSDI. Those are two seperate entities.
    If you have worked/paid into the SSA system, FICA taxes have been deducted from your wages for 10+ years...you have enough points to qualify, if you are found 100% disabled under SSA definition/rules.
    You won't know that unless you make the application and go through the process.
    However at 30 years, it's much more difficult that being 50+

    At this point, based on the info you have provided, IMO...you are not a candiate for any WCMSA or Medical Setaisde arrangement, by law. \
    '
    You are wise to be looking into this, and exploring the possibilities, but I dont' think you need to go further at this point in time.
    settlement which means you get less and the IC gets to keep
    You're right... a cash settlement to close the claim would always be in the ER/IC best interests. As long as you are being paid benefits, the claim is open, and you have access to medical care. Nothing wrong with that... surely better than paying out of pocket.

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