Scott, please...Section 32 Agreement - Future Medical

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Latest post 01-30-2008 9:54 AM by Scott Clippinger. 11 replies.
  • 01-23-2008 8:46 PM

    Question [=?] Scott, please...Section 32 Agreement - Future Medical

    If I were to enter into a Section 32 Agreement for all past and future claims from my injury, if I needed future medical care for these controverted body parts, would my regular health carrier and/or future health carriers, including Medicare when I am eligible, deny payment for any medical bills as a result of these injuries? It seems trying to estimate the future cost of medical treatment for various unknowns at this point is difficult as all the medical issues have not yet been sorted out. There's no way I can leave myself having to pay future medical out of pocket.

    If the answer to this question is yes, is there a way to prevent this problem by certain wording in the Section 32 Agreement?

    Thanks again, Scott.
  • 01-23-2008 10:15 PM In reply to

    re: Scott, please...Section 32 Agreement - Future Medical

    The answer is that no one knows for certain. I have not heard of a carrier raising the issue of prior settlement of future medical benefits--but it doesn't mean that a health carrier won't get creative in the future. You should not have difficulty with Medicare as long as you settle prior to receiving Medicare and prior to the reasonable expectation period. I would not expect Medicare to successfully raise the issue if you meet the criteria for not obtaining a CMS review. Private carriers could be another issue--and I just don't know how it will be treated. My experience shows that folks get the coverage for future medical, but that doesn't mean it will continue. For years WC folks settled their cases, including medical, and immediately switched over to Medicare for coverage. Medicare caught on, and we now have the CMS review.

    What's truly silly in this whole thing is that NYS has elected to have the offset run in favor of SSD. Many other states the offset runs in favor of WC. Prior to CMS review, SSA offset the entire amount of a settlement against future SSD benefits. The net result was that SSD got the full benefit of the settlement value. Now CMS review, the set-aside is not off-set against SSD, and Medicare/SSD may lose the benefit of the set-aside if there is no need for it. Prior to the CMS set-aside, the entire settlement was offset; now the offset is diminished by the value of the set-aside. A whole new layer of beauracracy to accomplish naught.
  • 01-23-2008 10:49 PM In reply to

    Question [=?] re: Scott, please...Section 32 Agreement - Future Medical

    Thank you once again, Scott.

    Could you please explain a CMS review? I'm not at all familiar with that term.

    Also, what is the "reasonable expectation period"?
  • 01-24-2008 10:31 PM In reply to

    re: Scott, please...Section 32 Agreement - Future Medical

    CMS (Center for Medicare & Medicaid Services) will review the medical expense history of a claim, and the potential for future meds, and life expectancy, to determine an amount it believes will equitably be necessary to cover the future meds prior to Medicare kicking in.

    The period of reasonable expectation is 30 months. If you are not on Medicare at the time of settlement, and do not anticipate applying for Medicare within the next 30 moths, then CMS review for Medicare set-aside purposes is not required.
  • 01-25-2008 12:42 AM In reply to

    Question [=?] re: Scott, please...Section 32 Agreement - Future Medical

    Scott,
    If you settle a 32, and not receiving SSDI and, don't anticipate receiving Medicare, then this won't affect a sec. 32 but; what happens if you've filed for SSDI and am not received SSDI benefits yet, but, may within a year; will this affect the 30 month rule, or, is SSDI a whole different monster?
  • 01-25-2008 7:54 AM In reply to

    re: Scott, please...Section 32 Agreement - Future Medical

    Yes, that would trigger the 30 month rule. The issue is not whether you participate in Medicare, but whether you are eligible to participate. When you receive SSDI you can receive Medicare, and so you would require CMS review.
  • 01-26-2008 12:56 AM In reply to

    Question [=?] re: Scott, please...Section 32 Agreement - Future Medical

    Scott,

    Is the following a good site to use in reference to this subject?
    Thanks.


    http://www.cms.hhs.gov/WorkersCompAgencyServices/04_wcsetaside.asp
  • 01-26-2008 9:10 AM In reply to

    re: Scott, please...Section 32 Agreement - Future Medical

    That's the proper site. Check it before you settle, as this is a moving target. The CMS is evolving, and changes the criteria on the run.
  • 01-28-2008 1:53 PM In reply to

    Question [=?] Scott ,can you please

    Scott,
    I have been collecting WC benefits for a back injury for more than a year.I have 2 other cases pending with same employer with hearings schedued.Once these other cases have been established and lets say the IC wants to settle all 3 cases once classified. From my understanding there is no medical once I accept a settlement is this true?. I have applied for SSDI .Does this effect my settlement and what role does this set-aside play in recieving my settlement.Im interested in finding out what the procedure is.and what this CMS review is. I want to rehab and try to get back into the work force.What happens once I start collecting SSDI checks?...confused, because im only getting bits and pieces of information from my attorney.Hope im explaining this correctly
  • 01-29-2008 8:44 AM In reply to

    re: Scott ,can you please

    If you are receiving, or about to receive, SSDI at the time you settle, the CMS will require a review to determine the amount of a set-aside--money to be taken from the settlement and put in trust to cover future medical expenses. This is only if you are settling you indemnity and medical. If you settle only the indemnity payments, there is no need for a CMS review, as the medical continues. Some carrier are willing to do that type of settlement. If there is a CMS set-aside, that amount must be expended on causally-related medical expenses before Medicare will pick up.

    If you start receiving SSDI payments, and wish to pursue rehab, SSDI has a plan whereby you can attempt a return to work and not jeopardize your payments. If the job is not possible with your disability, you would return to SSDI payments without penalty. It's the ticket-to-work program. If you go to the SSD site, you'll find plenty of information.

    You're confused, and so is the rest of the world. This is a complicated mess we've created. There are many curves that can be thrown. When you say you are only getting bits and pieces of information from your attorney, that sounds about right. No one has a complete handle on this, and rules are changed frequently. When you add into the mix the fact that each worker's situation is unique, from their past work experience to their current medical condition, it just makes it that much more difficult to evaluate a situation and advise how the myriad folks involved (carrier, Special Fund, CMS, WCB, SSD, etc) will treat any particular situation.

    Good luck . . .
  • 01-29-2008 10:49 PM In reply to

    Thank you

    Scott I thank you for your time and input. Since becoming a member of this board i have learned an abundant amount of information.I now understand the set aside amount. Do you know usually what % they take for lets say a 166k settlement. Lower back injury.herniated disc
  • 01-30-2008 9:54 AM In reply to

    re: Thank you

    There is no "usual"--depends on the degree of the injury, the past history of medical expense, the life expectancy, and the anticipated future medical expense.
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