Medicare Set-Asides for Personal Injuries
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 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.
Medicare Set-Asides for Personal Injuries
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 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 deadline to 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) the following.
Loss of bodily function
Some workplace accidents can result in the loss of one or more of your critical body parts, such as the loss of eyesight or hearing. Many accidents can affect your sight or hearing, including getting shrapnel or chemicals in your eye, exposure to overly bright lights, exposure to loud noises, explosions that injure your eardrum, and more. Such accidents might injure one or both of your eyes or ears.
Losing one or more of your bodily functions can have devastating effects on your life. You will need medical treatment. Some people need to have an eye removed and replaced with a false one, or they might need hearing assistance devices for the rest of their lives. Injured victims might need ongoing occupational therapy and other treatment, and they might not be able to return to their previous jobs due to their permanent disabilities.
Amputation
When a worker loses an extremity (arm or leg), it is often because an incident crushed, mangled, or severed a major portion of the extremity. The accident itself might sever the limb or extremity, or a crush injury and compartment syndrome might require surgical amputation.
In either situation, losing a body part that you use every day is devastating and completely alters your life on the spot. Victims need emergency trauma care, and then they start on the long road to learning how to live life without the amputated part. Even with prosthetics, it can take significant time, pain, frustration, and effort to adapt to life with an amputation.
In addition, should a victim choose to wear a prosthetic, they will face those costs for years to come. These devices need replacement every few years, and someone might have several if they engage in different types of sports or activities. Further, many people who suffer amputations at work can no longer perform those job duties, and they must either find different work than they initially chose for their lives or possibly even quit working altogether.
Paralysis
Any trauma to the spinal cord can be frightening because of the potential effects of this type of catastrophic injury. Complete spinal injuries occur when trauma completely severs the spinal cord, which cuts off the ability of messages from the brain to reach parts of the body below the injury. This means that victims of complete spinal cord injuries experience total and permanent paralysis in those areas of the body, which could include below the waist, part of the torso and below the waist, or even from the neck down.
There is no doubt that the permanent loss of sensation and movement in large areas of the body—including the limbs—will instantly and completely change your life. People might choose to use wheelchairs and other assistive living equipment, and they will likely need accommodations to their homes and/or vehicles. Some people with high spinal injuries need assistance to even breathe, and they might experience serious and ongoing health complications.
The lifetime cost of paralysis for someone who is still of working age can reach millions of dollars. This cost not only addresses the lost earnings from the disability, but also the life-long medical care and assistance they will need.
Traumatic brain injury
Any type of trauma to the head can result in a traumatic brain injury (TBI), which occurs when the brain tissue sustains damage. Some TBIs leave victims in a coma for days or weeks in the intensive care unit (ICU), and when they awake, they might have severe memory issues and need to relearn simple information about their lives or how to perform even the most basic tasks.
Even without a coma, TBI victims can experience a wide range of life-changing impairments, many of which are difficult to overcome or are permanent. These effects can be:
- Cognitive – TBIs can affect the way your brain processes information, and difficulties might involve following directions, written or verbal communication, reading speed and comprehension, and much more. These impairments can be particularly difficult to deal with since they are “invisible” effects of the TBI.
- Behavioral – Another invisible effect of a brain injury affects a victim’s behavior, including impulse control, anger management, mental disorders, and other challenging changes.
- Physical – Some TBI victims have visual cues regarding their injuries, which can include gait issues, lack of coordination or balance, slurred speech, and muscle weaknesses, among others.
The symptoms and effects of a TBI will depend on which part of the brain sustained damage and the severity of that damage. No matter what combination of effects you might feel, this type of injury can be catastrophic and life-changing. Many people with TBIs can no longer work, whether their jobs require physical strength or sharp cognitive skills.
Severe burn injuries
Another catastrophic injury that is often overlooked is a severe burn. Third-degree burns damage all layers of your skin, plus additional tissue below the skin, such as muscle, ligaments, tendons, or bone. These burns tend to throw victims into shock, and they need immediate medical help and trauma care.
The treatment process for third-degree burns is often long and painful. Many people spend time in a burn center where medical staff can monitor them, treat their wounds, and work to prevent infections. Once the burn starts to heal, surgeons might discuss skin grafts or other painful procedures. Many patients require multiple skin grafts to repair a single area of skin, and the process can be significantly worse if you have large areas of burned tissue.
Even when your burn treatment is complete, you might face a lifetime of disfigurement and disabilities. You might have limited movement in scarred areas or, in severe cases, you might have an amputation of a body part that could not recover from the burn injury. Many people struggle to work or engage in everyday activities following third-degree burns, and this injury can affect their lives in many costly ways for years to come.
In some 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 and the workers’ compensation benefits that might be available if you suffered a life-changing injury. You always want an attorney who knows how to seek maximum benefits for lasting impairments and permanent injuries.
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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