Medicare Set Asides… …the untold story
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Transcript of Medicare Set Asides… …the untold story
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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…..
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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
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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
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Questions
Karen Shelton, RN, CNLCP, LNC
ProjectWorks, Inc.
843.270.0140
www.projectworksinc.com
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