If you sustained Medicare-eligible disabilities, reaching a final insurance settlement requires you to factor in Medicare set-asides.
Read on for why you will want a lawyer to help you through this complex process.
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Medical Insurance Claims and General Personal Injury Settlements
When a personal injury victim seeks medical care, he or she will nearly always use personal health insurance to pay for the care. When you reach a final settlement, the insurance company is entitled to collect the money that it paid toward your care. This is known as subrogation.
In some cases, Medicare is a secondary payer (for example, if the injured party was a senior or person with a disability). Until 2007, however, there was no mandate requiring Medicare notification when a personal injury claim reached a final settlement, even if Medicare had been a secondary payer of medical bills.
This often meant the primary insurer was reimbursed, but Medicare was not reimbursed for any costs that it paid. This changed with the implementation of the Medicare, Medicaid, and SCHIP Extension Act of 2007, however, and violations can prove costly for both personal injury victims and their attorneys.
With the passage of this law, insurance programs operated by the government must receive a notification when a worker’s compensation claim is filed, although the law does not require any medicare set-asides in the event of other types of personal injury claims. Don’t expect this loophole to be closed in the future.
When a claim has to do with worker’s compensation, the law requires the following:
- For victims who are Medicare beneficiaries: when a settlement is greater than $25,000, calculations are done to set aside two years of medical bills and wages.
- For victims who may be Medicare beneficiaries within 30 months: when a settlement is greater than $250,000, the same calculation as a current beneficiary must be performed.
Understanding How a Set-Aside Works
Medicare is only allowed to assert liens on past medical damages for services rendered that are actually part of the liability claim. Often, this takes an analysis of the medical expenses to decipher what medical treatment is related to the third-party claim. To determine what amounts you must set aside, you will create a life plan.
The life plan is developed with an understanding of the following issues:
- Anticipated medical bills, including long-term nursing care and medical appliances
- Necessary home modifications that the victim’s injuries require
- Daily living expenses, such as housing and utilities, clothing, and personal care
- Income the victim will lose as a result of their injuries
- The projected life expectancy of the victim
Once all this information is compiled, a victim’s personal injury attorney can then determine the dollar value of the victim’s claim. This calculation often involves the use of a future value calculator.
Keep in mind, this data is currently used primarily for workers’ compensation cases to protect victims from losing or lacking coverage over their lifetimes. However, these calculations can also help your attorney determine how much to pursue in a personal injury settlement for non-workers’ compensation claims.
Understanding Workers Compensation Rules
State laws require virtually all employers to carry workers’ compensation insurance to pay for medical costs and lost wages when an employee suffers an injury or illness related to work.
In Nevada, for example, employees have 90 days from the date of an injury to seek medical care, and as a result, have the injury reported. Once reported, the workers’ compensation insurance company has 30 days to either begin paying benefits or issue a denial.
Employees do not need to prove fault to collect workers’ compensation benefits, but workers comp only pays for economic damages, not unquantifiable damages like pain and suffering. And you will still want a lawyer to help you apply for your benefits and reduce the chances of a denial—and if the insurance company does deny or reduce your benefits, to help you appeal.
However, in some cases, the employer is not responsible for either the illness or injury that the employee has suffered. At-fault parties may include contractors, other employees, vendors, or manufacturers of tools or equipment responsible for the injury or illness. In these third party cases, injured or ill workers can pursue compensation for pain and suffering.
Denial of Workers’ Compensation Benefits
When your employer or its insurance company denies your claim, you have a certain period of time to file an appeal. While most employees can file a claim on their own, it is usually a good idea to speak with a workers’ compensation attorney first, so you understand your rights and responsibilities.
If you receive a denial, you have a limited time to file an appeal. This is when working with an attorney could be crucial; you do not want to lose benefits because you have missed an important deadline for appealing a denial of your claim.
Catastrophic Injuries and Workers’ Compensation
Insurance companies that administer workers’ compensation benefits must treat significant injuries differently than other injuries.
Catastrophic injuries include (but are not limited to):
- Loss of body function – Loss of eyesight or hearing (one eye/ear or both eyes/ears)
- Amputation – When a worker loses an extremity (arm or leg), or a major portion of the extremity is crushed, mangled, or amputated.
- Paralysis – Injury of head or spine, resulting in partial or complete paralysis of arms/legs
In other instances, an injury may qualify as catastrophic, or doctors may not initially qualify an injury as catastrophic but change the classification down the road. You can speak with an accident injury attorney to learn more about these cases
Victims of workplace injuries often have a lot of questions regarding their claims and their rights, and they do not always know if they are being treated fairly by the involved insurance companies.
If you have any questions or concerns about a workers’ compensation claim or a workplace accident case, you should contact an experienced workers’ compensation lawyer that has experience dealing with Medicare set-asides. Most personal injury attorneys offer free consultations, during which you can discuss the details of your situation and ask questions about your rights and options.
If you sustained Medicare-eligible disabilities, reaching a final insurance settlement requires you to factor in Medicare set-asides.
Read on for why you will want a lawyer to help you through this complex process.
Medical Insurance Claims and General Personal Injury Settlements
When a personal injury victim seeks medical care, he or she will nearly always use personal health insurance to pay for the care. When you reach a final settlement, the insurance company can collect the money that it paid toward your care. This is known as subrogation.
In some cases, Medicare is a secondary payer (for example, if the injured party was a senior or person with a disability). Until 2007, however, there was no mandate requiring Medicare notification when a personal injury claim reached a final settlement, even if Medicare had been a secondary payer of medical bills.
This often meant the primary insurer was reimbursed, but Medicare was not reimbursed for any costs that it paid. This changed with the implementation of the Medicare, Medicaid, and SCHIP Extension Act of 2007, however, and violations can prove costly for both personal injury victims and their attorneys.
With the passage of this law, insurance programs operated by the government must receive a notification when a worker’s compensation claim is filed, although the law does not require any medicare set-asides in the event of other types of personal injury claims. Don’t expect this loophole to be closed in the future.
When a claim has to do with worker’s compensation, the law requires the following:
- For victims who are Medicare beneficiaries: when a settlement is greater than $25,000, calculations are done to set aside two years of medical bills and wages.
- For victims who may be Medicare beneficiaries within 30 months: when a settlement is greater than $250,000, the same calculation as a current beneficiary must be performed.
Understanding How a Medicare Set-Aside Works
Medicare is only allowed to assert liens on past medical damages for services rendered that are actually part of the liability claim. Often, this takes an analysis of the medical expenses to decipher what medical treatment is related to the third-party claim. To determine what amounts you must set aside, you will create a life plan.
The life plan is developed with an understanding of the following issues:
- Anticipated medical bills, including long-term nursing care and medical appliances
- Necessary home modifications that the victim’s injuries require
- Daily living expenses, such as housing and utilities, clothing, and personal care
- Income the victim will lose as a result of their injuries
- The projected life expectancy of the victim
Once all this information is compiled, a victim’s personal injury attorney can then determine the dollar value of the victim’s claim. This calculation often involves the use of a future value calculator.
Keep in mind, this data is currently used primarily for workers’ compensation cases to protect victims from losing or lacking coverage over their lifetimes. However, these calculations can also help your attorney determine how much to pursue in a personal injury settlement for non-workers’ compensation claims.
A Workers’ Compensation Attorney Can Help with Every Aspect of Your Claim
Victims of workplace injuries often have a lot of questions regarding their claims and their rights, and they do not always know if they are being treated fairly by the involved insurance companies. Whether you need to file a claim, appeal a claim denial, or comply with Medicare set-aside requirements, you want the right legal assistance.
If you have any questions or concerns about a workers’ compensation claim or a workplace accident case, you should contact an experienced workers’ compensation lawyer that has experience dealing with Medicare set-asides. Most personal injury attorneys offer free consultations, during which you can discuss the details of your situation and ask questions about your rights and options.
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