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Medicare Set Asides……the untold story
SC WC Educational Conference
March 1, 2010
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Worker’s Compensation
Medicare Secondary Payer (MSP) regulations have made settling
Worker’s Compensation cases extremely complex, challenging,
and confusing…..
Confusing for….. The client The doctor The carrier The defense attorney The plaintiff attorney The providers
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Medical Treatment
Payment for injury related medical treatment post-settlement may be different from payment prior to settlement.
Hoke will explain more……..later
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Overview: Work Comp
No fault insurance program
providing medical and wage
loss benefits
Provides 12 basic components
of medical benefits
WC Medical Benefits
Inpatient treatment
Outpatient treatmentPrescription drugsClaim’s administrationPremium for inpatient treatmentPremium for outpatient treatmentPremium for prescription drugsPayment of co-pays and deductibles, medicalPayment of co-pays and deductibles, drugsPayment of drugs not covered by MedicarePayment of medical care not covered by MedicareTransportation
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1. Inpatient Treatment
When transitioning into Medicare:
Medicare Part A, requires a premium
Deductibles for each occurrence
Daily charge for extended stays
Blood transfusion exclusion
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2. Outpatient Treatment
When transitioning into Medicare:
Medicare Part B, requires a premium
80/20 co-pay on most services
50/50 co-pay on mental health
Annual deductible
Significant exclusions
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Exclusions
home attendant care
home modificationsmodified vans and maintenanceequipment maintenancetransportation vision and dental serviceshearing testing and equipmentcare outside USA
limited chiropractic treatment
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3. Prescription Drugs
When transitioning into Medicare:
Medicare Part D, premium required
Annual deductible, first $310 at 100% co-pay
25% co-pay between $310 and $2,830
100% co-pay between $2,830 and $6,440
5% co-pay over $6,440
True Out Of Pocket expenses (TrOOP)
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4. Claim’s Administration
When transitioning into Medicare:
Can be self administered or through a
professional custodial administrator.
CMS will require professional custodial
administration for cases of brain injury or incompetence.
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5. Premium for inpatient care
Carrier responsible if WC
Medicare Part A
based on quarters worked
typically free
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6. Premium for outpatient care
Carrier responsible if WC
Medicare part B
2010 monthly cost is $110.50
taken out of SSDI or SS check
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7. Premium for prescriptions
Carrier responsible if WC
Medicare part D
national average $32.00 (2010)
purchased privately
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8. Co-pays and deductibles
Carrier responsible if WC
Significant co-pays and deductibles if
coverage under Medicare
Supplemental policy (Medigap)
cost varies by county
purchased privately
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9. Co-pays for prescriptions
Carrier responsible if WC
Injured worker responsible if in
Medicare Insurance Program
True Out of Pocket (TrOOP) expenses
Donut hole
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10. Non Covered Drugs
Carrier responsible if WC
Over the counter drugs not covered
Certain prescription drugs not covered
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11. Non Covered Medical Treatment
Carrier responsible if WC
Injured worker responsible if in
Medicare Insurance Program
Significant exclusions and
out of pocket expenses
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12. Medical Transportation
Carrier responsible if WC
Injured worker responsible if in
Medicare Insurance Program
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Summary of ComponentsInpatient treatment
Outpatient treatmentPrescription drugsClaim’s administrationPremium for inpatient treatmentPremium for outpatient treatmentPremium for prescription drugsPayment of co-pays and deductibles, medicalPayment of co-pays and deductibles, drugsPayment of drugs not covered by MedicarePayment of medical care not covered by MedicareTransportation
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Worker’s Compensation
All 12 components provided
Future medical cost projection
to show potential lifetime exposure
Need apportionment for Medicare
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Overview of the MSA
Not a Life Care Plan or FMCP
Apportionment tool
Protects Medicare’s exposure
Uses discounting factors
CMS pre-settlement review thresholds
Guide for post-settlement medical payments
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MSA addresses:
Inpatient treatment
Outpatient treatment
Prescription drugs
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Overview of the NCA
Not a Life Care Plan or FMCP
Companion report to the MSA
Protects Claimant’s exposure
Reflects current treatment plan
Uses chronological age life expectancy
Offers due diligence discovery
Not required, but…..
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NCA addresses:
Claim’s administration
Premium for inpatient treatment
Premium for outpatient treatment
Premium for prescription drugs
Payment of co-pays and deductibles, medical
Payment of co-pays and deductibles, drugs
Payment of drugs not covered by Medicare
Payment of medical care not covered by Medicare
Transportation
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Or…..Inpatient treatmentOutpatient treatmentPrescription drugsClaim’s administrationPremium for inpatient treatmentPremium for outpatient treatmentPremium for prescription drugsPayment of co-pays and deductibles, medical Payment of co-pays and deductibles, drugsPayment of drugs not covered by MedicarePayment of medical care not covered by MedicareTransportation
Questions
Karen Shelton, RN, CNLCP, LNC
ProjectWorks, Inc.
843.270.0140
www.projectworksinc.com
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