Your Guide To Medicare Set Asides

Virginia and North Carolina Workers Compensation Attorney Joe Miller here breaks down, in simple, easy-to-understand terms, the basics of Medicare Set-Asides (MSA's)--What is it and why do you need one in your workers comp settlement? You just received some kind of authorization for a company you have never heard of that you are being asked to sign. The Authorization gives this company the authority to obtain all of your medical records and submit them to something called CMS. What the heck is going on? Joe Miller explains all in this comprehensive explainer video on MSA's.

[@lindas.3791]

I have ignored all the CMS letters. Then they stopped sending them. i just received a letter from them. I pay my pain doctor and the prescribed medicine myself. I did keep the receipts. I just don't see my regular doctors for any of my work compensation injuries.

[@lindas.3791]

Unfortunately my attorney said i could spend the money. So now I'm screwed.

[@elsierodgers4874]

You made it very clear, thanks. I'm searching for self administered msa, sort of confused about the self administered msa, but thanks again for some clarity.

[@TMcGlynn23]

Thank you for this information. Your advice has really helped me figure out what I need to do.

[@randymicklick4799]

Thank you Joe Miller this video answer questions that were stressing me out. I very much appreciate your video brother and may God richly bless you and your law firm and your family your brother in Christ Randy.♥️🙏🏻

[@JoeMillerLaw]

Thank you so much, sir, very much appreciated.

[@lazaroibarra8464]

Very good information. After three years and four months and a few hours of my accident, I'm starting to receive this medicaid set aside paperwork. It is overwhelming. You really did help. Thank you.

[@JoeMillerLaw]

So glad we were able to help. That makes my day.

[@benalexender3046]

Thanks

[@JoeMillerLaw]

You are very welcome.

[@BearPapa49]

This makes a lot of sense thanks

[@andrewwilliama9216]

Very informative. Think You

[@scottfreeman5854]

Ty for the video !!! I just settled an old comp case of which I've been on Medicare since 2000 ( psych Injury ) ... I've spent some of my MSA and need more from It .... I've heard I can be taxed on It ( how ) but I do not file bc I'm on SSDI ? Also, would something Like Dimentia be challenged by Medicare to not pay or Is that a gray area ? Should I seek an attorney or contact my WC attorney that handled my case ? Ty very much for your time !!!!!

[@ondriajeannettes2636]

Was it due to work? If so can you share! Because I just been released from a mental hospital 🏥

[@JoeMillerLaw]

Here is the link I refer to in the video. Hope this is helpful: www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Overview

[@Tomedu2021]

Very good information, can the CMS be different than the initial proposal?

[@JoeMillerLaw]

Yes it happens frequently

[@30pvfd]

Will you get notified of their “blessing” if cms approves the sba

[@overrunwithboys216]

0 seconds ago Seeking Lawerly advice: I've read of MSA nightmares, how that sometimes the "Set Aside" denies the claim, then Medicare denies the claim, then you need a Lawyer to help get ANYTHING paid. Husband had a Open wound multi fractured "Leg salvage" crush Injury, Steel Mill accident, .. His injury required a Muscle and artery to be removed from his thigh & sewn into his lower leg, 11 hr Skin Flap surgery, 7 months later, Bone Graph surgery ....He's healed wonderfully... BUT he's Pre-diabetic, 60 yrs old (this happened 2 yrs ago)- still on Workman's comp as I write this... I have a huge fear ... he may have major Leg complications IN THAT LEG if he comes down with Diabetes in the future , then what, who pays... as I can easily see the MSA saying it's NOT related (but wouldn't it be after 9 surgeries, numerous CT scans, a rod, nerve damage & a sewn artery & Muscle to his lower leg,), his Pain Doctor said to him "he basically has a Diabetic leg NOW"... He also has Drop foot..... can you see both the MSA and Medicare denying these claims ? What is your expert Lawyerly advise to a situation like his. I'd personally prefer to keep the Medical Open but even with that, the Workmans Comp Insurance could still say -if he has complications, it's not related to the injury, or could they?

[@JoeMillerLaw]

I"m so very sorry about your husband's injuries. It sounds like he's really been through the ringer. As I always say, my knowledge of workers compensation law is limited to VA and NC and i do not know where your Husband's comp claim is pending. But it would be governed by the laws of that State. First and foremost, everything depends on what the Medical Award is for. If it's for whatever leg or lower extremity your husband injured, at least in VA, the diabetes might be a complicating factor, but as we always say in the law, "you take your claimant as you find them." In other words, I am assuming that pre-diabetes was present prior to the leg injury. So if that makes the injury worse, harder to treat, or more expensive to treat, then guess what? Too bad for the insurance company. In VA, as long as some portion of the required care is related to the work injury, or surgeries on the body part that is Awarded then the comp carrier must pay for it. Any MSA would also take all of that into account. Despite all of that, I regret to tell you that I am hesitant to give anyone advice-unless they are my client--- certainly without having reviewed the entirety of the medical file. In any event, i certainly hope you have an attorney who specializes in workers compensation in whatever state where your husband's claim is pending. If you do not have one, you need one now, particularly if the carrier is starting to talk settlement. I would never attempt a settlement on what sounds like a career-ending injury that you are describing without an attorney on your side.

[@Gerardoak-mq1qn]

Good evening, but what if I want to close my case completely and sell my doctor, I can grab all these benefits?

[@JoeMillerLaw]

Not sure I understand what ur asking, but once you settle you are no longer under the thumb of the comp insurance co & u can go to any doctor who will have you, using the MSA money to pay, of course.

[@dorothygreen4381]

Who is suppose to have the interest bearing account....the injured person ????

[@JoeMillerLaw]

This depends on whether the MSA is "self-administered," meaning yes, it would be the account of the injured person, whether in lump sum or paid out annually via an annuity, or whether the account is managed by some management company who pays out the funds to the medical providers as they become due. Those second type are not self-administered MSA's but managed MSA's and that account is not held by the injured person but the management company. In most cases I deal with, the funds are self-administered by the injured person, so yes, that person would need to set up a separate account at his or her bank.

[@30pvfd]

Is it true if you die your heirs get the money been told that

[@JoeMillerLaw]

Generally, yes, but as of late, more and more carriers are getting wise to this and putting a "reversion clause" into the settlement documents. This means that if you die, any money remaining in the MSA account reverts to the insurance company. It stinks, but I suppose their reasoning is that the purpose of a Medicare Set-Aside is to essentially replace Medicare coverage for your work injuries. You don't get any Medicare Coverage after you die, so why should your heirs benefit from something your estate would not otherwise receive? I think if they want to put one of those clauses into the mix at the last minute, it changes everything re the settlement dynamic. You bargained that your heirs would receive any unused funds in the MSA. So my position is if the carrier insists on one of these reversion clauses, then they need to make up for that on the indemnity side of the settlement by offering more $$.

[@drkrice333]

I settled my WC claim. I'm a Medicare recipient and I reached out to CMS and they told me that they will not review a MSA Allocation report that the WC insurance company received from a third party company. If the WC insurance company supposed to take care of Medicare's interests, are they supposed to still submit something to CMS showing the amount my full and final settlement with my MSA award included, for approval?

[@JoeMillerLaw]

Frankly, I have never heard of this. I'm not sure where the WC Insurance Company would obtain such a report, other than from one of these companies, unless they did it internally. They routinely obtain these third party reports, and to my knowledge, CMS reviews these kinds of reports every day. Either you spoke to someone new at CMS who really did not know, or it could be that there is a 2023 Addition to the MSA Guidelines which I have not seen yet. In 2022, for instance, they changed the game by basically not allowing any type of "work-around" to obtain a CMS-Approved MSA for Medicare Recipients. Sometimes WC Insurance companies would do a "work-around" by including specific, WC Commission- mandated language in the settlement agreements that the insurance co guaranteed it would step in for any shortages to protect Medicare. After 2022, CMS has basically said they would not honor those and you engage in those workarounds at your peril. In any event, I'm curious as to whether the WC insurance company has already prepared a report and sent it to CMS for review? Takes about 6-8 weeks for the results to come back. Only other thing I could think of is if your entire claim is valued inder $25K. CMS does not review those, and such review is not required, even if you're a current Medicare Recipient.

[@drkrice333]

@@JoeMillerLaw Thanks for the reply. I've reached out to CMS and they don't have anything for review on file nor do they have anything on record. The insurance company had ISO Claims to work up an MSA on me and I received it in December of last year. We settled my case on Thursday of last week and the entire settlement is over 100k.

[@JoeMillerLaw]

@@drkrice333 Not sure if you have an attorney. If you do, you should ask him to contact the defense and ask if the MSA has been submitted to CMS for review. If you are a current Medicare recipient that should have been taken care of prior to settlement. If not, you are playing with fire. Now I will say that sometimes what we do is we settle the indemnity first and leave the medicals open while the defense goes through the process of submitting the MSA report and getting CMS's response. It is certainly possible that is what happened in your case, but I don't know enough about your situation to comment past what I've said already. If you are not represented, you need to find out why the MSA was not submitted to CMS for review by contacting the defense folks. If it was submitted and CMS had a response, you would have received that response from CMS.

[@drkrice333]

@@JoeMillerLaw Now that was the confusing part of it. I had a Mediation on the 16th of this month and both parties came to an agreement. The MSA was created by ISO Partners back in Sept of last yr and it wasn't submitted to CMS for review. Someone dropped the ball in my opinion.

[@JoeMillerLaw]

@@drkrice333 I would definitely stay after the carrier to get that submitted. They may have to get an updated MSA. September may be so old that CMS wont' look at it now until it's updated.