• A widow or widower may receive full benefits at full retirement age or partial benefits as early as age 60.
• A disabled widow or widower – as early as age 50 (pursuant to Social Security’s definition of disability).
• A widow or widower at any age if he or she is caretaker of the deceased’s child who is under age 16 or disabled and receiving Social Security benefits.
• Unmarried children under age 18 or up to age 19 if they are attending high school full time. There are some circumstances in which step-children, grandchildren, or adopted children can also become eligible for benefits.
• Children at any age who were disabled before age 22 and remain disabled (per Social Security’s definition of disability).
• Dependent parents age 62 or over.
• Divorced spouses: If a divorced spouse dies, the surviving spouse can receive benefits if the marriage lasted at least 10 years and the surviving spouse is age 60 (unless disabled, then can become eligible as early as age 50). However, if remarriage occurs, there are special considerations that apply.

There is a maximum family benefit that applies in these cases. There is some variation in the calculations, but the maximum is usually between 150% and 180% of the deceased’s benefit amount.

Proper Social Security Benefits planning can be crucial to settling dependency claims and often makes the difference when figuring out what a surviving spouse will need as part of a settlement to maintain or improve his/her financial situation.

For the complete article, visit WorkCompCentral. For a copy of the complaint filed by CMS, click here.

This is a workers’ compensation claim involving full and final settlement for future medicals.  The MSA was prepared March 25, 2009.  Settlement documents were completed and approved by the judge in October 2009.  Because the MSA was done prior to CMS’ June 2009 revamping of prescription costs, donut hole, co-pays, etc., the MSA proposal would need to be increased to bring it in line with the changes.

The recommendation by my clients’ third-party vendor is to not submit the Settlement Agreement with MSA proposal to CMS for formal approval.  Their recommendation seems to be to make no changes to the MSA we already have. The theory is that the purpose of the Medicare Secondary Payer Act is to ensure that Medicare’s interests are considered and adequately protected when there is a settlement closing future medicals. There is no specific requirement stating that CMS approval is mandatory.

I appreciate there has never been a formal statutory requirement that parties to a workers’ compensation claim with MSAs for future medicals submit the proposals to CMS and gain formal approval.  However, my personal belief has been that the submission to CMS with the resulting letter from CMS approving the proposed MSA has provided at least some extra level of protection to my clients in case there is ever a question (or assertion) as to whether the MSA was properly funded.

I think regardless as to whether we ultimately submit the settlement with proposed MSA to CMS, at a minimum we would need to have the MSA revised and funded to account for the changes that became effective this past summer.  I am not sure how comfortable I am with the “let sleeping dogs lie” approach being recommended by the vendor.

MEDVAL answers:

For the record, we are not the vendor in question but would probably agree with their recommendations depending on the specifics of the case.

This attorney is correct that there is no formal statutory requirement to submit an MSA to CMS for approval (nor a requirement to do an MSA at all for that matter). She is also correct in her analysis that seeking CMS approval provides a benefit to her client, presumably the insurer. Namely, CMS has indicated that if the parties go through the formal WCMSA review process, CMS will probably not come knocking on anyone’s door in the future looking for reimbursement in the event the claimant eventually taps Medicare for treatment of a work related injury.

But it also has an associated cost. Sometimes a MASSIVE cost.

For example, we recently had a case where an MSA was prepared 18 months ago and the Insurer settled based on the amount at the time (around $130,000). When updating the MSA to new CMS protocols, the cost ballooned to over $500,000.  Not because the treatment changed, not because we used some sort of loophole to artificially reduce the MSA (more on that subject later) but solely because of AWP and the idea the CMS will look to the claimant’s current medication regimen as a reliable predictor of future utilization.

No one involved in the claim has any doubt that $130,000 is more than adequate to make sure this claimant never seeks Medicare coverage for her work related injury. Her exact drug regimen can be purchased for 60% less than the AWP pricing used by CMS. So the question becomes, is the CMS approval worth $370,000 extra dollars? Are the real and imagined risks of CMS “coming after” the insurer worth paying $370,000 today for an injury that will likely never consume the $130,000 originally set-aside?

I don’t know. That is a risk management decision for the client to make. If you want my opinion, as long as the MSA was based on a rational, logical and reasonable course of future treatment, then CMS has an almost insurmountable burden of trying to prove that the insurer did not meet their obligations under the MSP.  If the claim is worth $130,000 for future medicals than that is what should be set-aside. No more and no less.

I think it would be appropriate to look at what the new review protocols would cost relative to the actual value of the case and the amount that would reasonably protect Medicare’s interests. If it is in an acceptable dollar range and the client feels the review process provides a benefit, then by all means submit the case. If the MSA was calculated using some dubious method (like deducting the donut hole or using Medicare co-pays which in my opinion was a massive fraud perpetrated upon the insurance industry and genuinely injured workers to increase market share and profits by a few MSA vendors) then it should be recalculated to reflect the correct amount to be set-aside.  Not because CMS or WCRC protocols demand it, but because it is your client’s obligation under the MSP.

 
MEDVAL 1-888-SET-ASIDE

Medicare Set-Aside Allocation/Arrangement Recommendations

Submissions to Centers for Medicare and Medicaid Services

Post-Settlement Administration

Pharmacy Benefit Management

The long and short of it is that he has a CMS approval letter from 2007 approving $18,000 for the MSA. However, he is currently taking $15,000 PER MONTH in Medicare covered Rx which according to him is the full responsibility of his prior employer and the TPA.

The TPA is representing that the 18k MSA that was approved more than two years ago fully protects Medicare’s interest under the theory that MSA approvals never expire. The claimant is very hesitant to settle his case because he will spend the 18k in exactly 40 days instead of the 18.9 years it is projected to last. He wisely concluded that even if Medicare was to pay his claim under Part D, there would be substantial out of pocket funds required to fill his Rx going forward. (of course his settlement may be for 2MM and that isn’t an issue. Not enough information to draw a conclusion here).

So the question is, did the TPA adequately protect Medicare’s interest by relying on a two year old MSA that was approved by CMS or do they have a duty to add additional funds to the MSA since they have knowledge that the amount is completely inadequate? What liability does the employer, TPA and claimant have under this scenario?

What would you do if you were the adjuster, attorney or TPA? Comments welcomed.

  
MEDVAL 1-888-SET-ASIDE

Medicare Set-Aside Allocation/Arrangement Recommendations

Submissions to Centers for Medicare and Medicaid Services

Post-Settlement Administration

Pharmacy Benefit Management

http://www.cbsnews.com/video/watch/?id=5737138n&tag=api

While we deal primarily with issues concerning the Medicare Secondary Payer Act and CMS’ efforts to enforce the law, it seems like a tiny sliver of the pie when you examine the staggering end of life costs paid by Medicare. Last year it was estimated that Medicare paid $50 billion for expenses incurred for beneficiaries during the last two months of life.

The white elephant in the room is right in front of us yet there is precious little leadership willing to take on the issue. Medicare can have a blank check policy or fiscal solvency. I don’t see how it can have both.

CMS is going to have to hustle down a lot of $50,000 workers’ compensation settlements to balance that checkbook.

MEDVAL  1-888-SET-ASIDE

Medicare Set-Aside Allocation/Arrangement Recommendations

Submissions to Centers for Medicare and Medicaid Services

Post-Settlement Administration

Pharmacy Benefit Management

http://www.guardian.co.uk/world/2009/nov/23/man-trapped-coma-23-years

MEDVAL 1-888-SET-ASIDE

Medicare Set-Aside Allocation/Arrangement Recommendations

Submissions to Centers for Medicare and Medicaid Services

Post-Settlement Administration

Pharmacy Benefit Management

HIG Capital has reportedly been spending some serious capital upgrading the badly floundering PMSI. But clearly they are not at all interested in investing in the human capital required to produce a top notch Medicare Set-Aside product.

For a company that has been in the MSA business for a pretty long time, it is hard to believe they still don’t get it. Read their job description and then compare it to MEDVAL’s newest “MSA Specialist I”.

Description

MSA Specialist I:

 Responsible for the production of Medicare Set Aside Allocations.

Basic Functions:

• Reviews and analyzes medical records and Medicare payout information to determine an appropriate Medicare Set Aside (MSA) Allocation for recommendation to clients.
• Conducts research on Medicare expenses allowed in appropriate state for workers’ compensation and keeps abreast of all changes in law and Centers for Medicare/Medicaid Services guidelines.
• According to PMSI MSA Services guidelines, writes the MSA report, calculates financial grid for injury- and non-injury-related medical expenses and coordinates with PMSI for related pharmaceutical costs.
• Works with claim adjusters to obtain clarification on outstanding issues for MSA.
• Works with claim adjusters and attorneys in negotiating and defending recommended allocations as necessary.
• Works with Case Management Specialists in coordinating daily work deadlines per PMSI MSA Services’ production standards.
• Maintains level of 80 percent accuracy in monthly quality control evaluation.
• According to PMSI MSA Services guidelines, maintains a minimum production level of 25 Medicare Set-Aside allocations per month.

Requirements

Job Qualifications:
Education:

• Required: High School Education
• Desired: Bachelor’s Degree in Business Administration or Insurance, Bachelor’s of Science or equivalent experience

Work Experience:

• Required: Minimum of two years workers’ compensation or liability claims experience or RN with case management and workers’ compensation or liability claims experience.

Licenses/Certifications:

• Desired:  RN, CLCP, MSCC

***Please apply via our website:www.pmsionline.com***

MEDVAL’s newest team member:

MARILYN J. LARRIMER, JD/RN

• Practicing Attorney, Civil Litigation (21 years)
• Licensed Registered Nurse (21 years)
• Captain, United States Army Reserve (8 years)

BSN Nursing – University of Pittsburgh

Juris Doctor – Duquesne University

Who would you rather have doing your MSAs?

MEDVAL 1-888-SET-ASIDE

Medicare Set-Aside Allocation/Arrangement Recommendations

Submissions to Centers for Medicare and Medicaid Services

Post-Settlement Administration

Pharmacy Benefit Management