The rules for Medicare are complicated.
And the rules for Medicare set-aside benefits in workers’ compensation cases, if not followed correctly, can even cause you to have your Medicare benefits temporarily frozen.
How could that happen?
It has happened to some injured workers, even those represented by well-meaning attorneys. Let’s look at why.
Set Asides Are Designed to Protect Medicare
After settling a workers’ compensation claim for Medicare beneficiaries, your attorney may need to coordinate a set-aside arrangement (WCMSA) with Medicare, putting money aside from the lump sum settlement future medical expenses.
We are only discussing the set-aside here, but there is also something called “conditional payments” under Medicare that may apply.
The amount of the set-aside is determined by the Centers for Medicare and Medicaid Services (CMS). CMS has requirements that will delay your payments when settling a workers’ compensation case. That is why it is important that your attorney know how to minimize the delay, and to comply with CMS requirments fully and quickly.
There are two situations that may apply to you with the CMS:
- If you are already on Medicare, and your settlement exceeds $25,000 and is settled under section 20 of the workers’ compensation statute, then you need to set aside money.
- If you are likely to become a Medicare beneficiary within 30 months after the settlement and you are awarded more than $250,000. Likely Medicare recipients have either been turned down for benefits and are appealing, or are 62 and a half and expect to receive Medicare at age 65. Again, you must set aside money.
This money is put into an account to pay only medical bills from the work injury. If that money is spent and your injury still requires medical care, Medicare will again begin to pay for your treatment.
What if the Insurance Company Wins in Workers’ Comp Court?
If the extent of your medical care is disputed by the insurance company, and some or all of the settlement is overturned, you’ll be expected to reimburse the Medicare benefits first. Your attorney should handle this, but the insurer may not inform your attorney, and it can slip through the cracks.
If this reimbursement for Medicare is not taken care of, an attorney can even be punished by the court or found guilty of legal malpractice for not having protected the interests of a client.
If you think any of these situations may apply to you, please talk to the Wilton Law Firm at no charge. We’ll be happy to explain your rights to you.