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  • Medicare set-aside from WC

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    Old 02-04-2006, 09:45 AM   #1
    Sunnycal
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    Medicare set-aside from WC

    My husband is getting ready to settle with Worker's Comp and he is being offered a structured settlement (money paid over time) and a Medi-care set-aside. The way I understand the Medi-care set aside, they buy an annuity that puts a certain amount of money in an account each year. You use this to pay your medical bills and then bill Medicare (because he has SSDI) after the money runs out each year. Has anyone had experience with this? They have factored in doctor's visits, counseling, synvisc injections for his knee, etc. to come up with the yearly amount. (They are now in the process of redoing the estimate to include prescriptions--of course the biggest expense.) Has anyone had trouble getting Medicare to approve procedures for RSD? This all sounds like a big headache to me!
    Sunny

     
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    Old 02-04-2006, 09:59 PM   #2
    Skooze
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    Re: Medicare set-aside from WC

    Hi Sunny!
    I've been in your shoes or your hubby's before. I never heard of a medicare annuity, however, if he closes his wc case, and gets X amt. of dollars make sure it is high enough to live off of. Don't leave open your medical if that is what I think you are doing. Medicare now pays for meds, and if you are low income it's free. I s have saved $400 a month from this program. But if you are leaving your medical open,which it sounds like you are, that is a bad choice, because wc will still have a say in your hubby's medical decisions and treatments. The best thing to do is to cut the cord completely, (You will both feel so much lighter) and ask for MORE money, and have Medicare kick in. I pay only 20% of my dr's visits, or roughly $18. I'm sure every state is different. I have SSDI too. Meds are my biggest expense. But now they are $2 a script. It took me a month to straighten it out with the insurance co., but my dr. visits are minor compared to the meds. Sunny, are you working? Cause this will affect his elegibility. I'd be happy to answer zny more ?'s that you have. I would ask for MORE $$$ and no pay no dr bills, and let him be the captain of his health care ship. Hmmm Let me know how it goes. Aloha Skooze

     
    Old 02-05-2006, 10:39 PM   #3
    Sunnycal
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    Re: Medicare set-aside from WC

    This is a compromise and release. We are not getting future medical. The structured settlement part is that he gets a small lump sum, then payments for life. We can go anywhere we want with the medical money, which is separate from the payments. Unfortunately when they did their calculations, they didn't figure in the true cost of doctor's visits, so that fund will run out sooner than they think. Medicare requires this fund saying that the employer has to pay part of the bill so that Medicare isn't paying for everything.
    Skooze, you have hit on one of our dilemmas. I am employed and have good insurance. I can't get a straight answer as to whether my insurance will start paying for everything. (I know they say not to sign up for Medicare drugs if your present one is better.) My Blue Cross said that his lifetime maximum will get used up pretty fast, and that maybe my employer will try to get some of the money. To top it off, my husband's good pain management doctor does not take Medicare. So we're still trying to figure it all out.
    Sunny

     
    Old 02-07-2006, 06:46 PM   #4
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    Re: Medicare set-aside from WC

    Hi SunnyCal! Sounds like you're in a catch 22. I could think of better words. A Big Dilema you might say. Your Blue Cross probably won't cover him because it is a prexisiting conditon, I would presume--unless he had any medical paid by them since he has had RSD. I could think of an easy solution but not maye duable. But first, why doesn't his pain mgt. dr. take medicare? I assume you are in California, but over here, doctor's would take medicare over medicaid anyday, because they pay on time. I'm in sort of a pickle myself, and this month when they repeat my MRI that in July is now showing a possible tumour where they did my neck surgery at C6-C7, if I do have the C word in addion to RSD, then I already know how the govt. operates. My daughter who receives survivor benefits from her dad, when combined with my SSDI, I make too much to qualify for medicaid by $17 a month. If I have to, & I don't want to, but with cancer my home and all my assets would be eaten up by medical bills. If I didn't combine my daughter's income with mine, I would receive free medicaid--but she couldn't live with me.
    She would have to live with say my sister. What I was thinking of your situation is if you to were to seperate or divorce for medical benefits, would this be out of the question? You could still live together, and you own the home, but his income would then be seperate from yours, and he would qualify for medicaid. I know it sounds hasrsh, but you need to protect yourself. RSD over the long run will have huge medical bills in the long run as any chronic illness will. I attended seminars on this subject.
    My other suggestion is tell your attorney to redo the amount including your discounted medicare medical bills and the prescription drugs. Since medicare has taken over, my meds are about $50 more a month than they used to. The other downside to this is if he doesn't sign up for medicare by 5/31/06, he'll be penalized by 1% each year or month, that he didn't take it, just like medicare Part A & B. See if you weren't married your incomes would be seperate. Also Medicare counts one home for free, but with medicare and medicaid you can own as many autos as you want to, and they don't count them as an asset. I currently own 5 cars. When I found out that I might have cancer, I did my homework. I would definitly consult an attorney on this matter or a financial planner, before signing anything. I hope I helped somewhat, believe me it's a complex case, as most of do have with different variables. Have your tried calling social security? Good luck and keep us posted . Aloha Skooze

     
    Old 02-07-2006, 08:48 PM   #5
    Sunnycal
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    Re: Medicare set-aside from WC

    Thank you, Skooze, for your ideas and experience. I hope you can get all of your medical problems sorted out (and that it is NOT cancer). Yes we are in California. My Blue Cross has been covering my husband all along, for the non-work related problems (angiogram, cholesterol medicine, etc.), so he would not have to apply for anything new. They even approved the Lyrica when we had a snafu with WC. (We reversed it when WC approved it so they didn't end up ultimately paying for it, though.) But you are right, the costs will add up fast. (His PM doc does not take Medicare or Medi-cal. He does take Blue Cross PPO, so that is why we are thinking about it.) The WC insurance company is in the process of redoing the offer right now, to include a prescription allowance, so I guess we will wait to see what happens on that. In figuring his SSDI allowance, they don't count my income (which we thought was amazing). We don't have a lawyer yet. Unbelievably, we have not had problems getting things approved by WC and we have been dealing with them on and off for 13 years since his accident (the RSD was the last 3 years, but he had 15 surgeries or procedures before that). Sometimes it has taken awhile, but they have ultimately approved everything (I hate to even admit that, because I know so many people have had such an awful time with WC. The rules were definitely more liberal in 1992.)
    I am trying to get in touch with my benefits technician, but unfortunately the real one is out on maternity leave, so I have left messages for her replacement!
    Thanks again and take care,
    Sunny

     
    Old 02-08-2006, 09:23 PM   #6
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    Re: Medicare set-aside from WC

    Hi Sunncal!
    WOW I can't believe that you've been dealing with this for 13 years with your insurnce co. and they are now ready to settle?????
    I know that you don't have a lawyer yet, but lawyers are necessary evils. I don't know what they do in CA., but in HI., they can only take 10% of your settlement, which is a drop in the bucket compared to what they can point out, (ex. things that you never thought about) that once you sign, the story is over. You are so lucky that they have not denied your hubby treatment, and that you don't have to count your income. I'm curious, why do you want to settle now, if things are being paid and you have no qualms????
    Why do you want to close the door on something that seems to work so good?? If I were you, & this is just someone looking from the outside & looking at what it is, I would pull out the yellow pages and run it by an attorney, usually they give a free consultation. It always makes me nervous signing that line. It's closure, yes & you will feel so much better with such a weight off of your shoulders, but I want you to be protected legally, because once you sign on that dotted lign---there is no recourse. And food for thought, what happens, if something else comes up in your hubby's health, that it isn't covered, for example like me, possible cancer??? Do they add all these factors into the settlement??
    I guess I worry too much. I closed my case 2 years ago, & I have never been happier The cancer or bone tumour-- who would have known. I just protect my assets, with the help of a paralegal or an attorney, but never do things, blind sided. I shudder to think the word "IF".
    I hope I made some good points to think about and other's who want to close their case, because we all want the monkey off of our backs along with monetary allowance for our pain & suffering, but we need to see the forest beyond the trees. I wish you luck & if you have any further ?'s fire awy. Good luck--I'm praying for you! Aloha Skooze

     
    Old 02-09-2006, 09:53 PM   #7
    Sunnycal
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    Re: Medicare set-aside from WC

    Skooze, thank you for your care and concern. This settlement was not our idea at all. We have been happy with the way things were going. The doctor declared him permanent and stationary last year. So this is the next step. They notified us last year that my husband had one year (up until this next June) to be seen by his present doctor, and then he had to go to a panel doctor. (Schwartzenegger's new regulations). We want to be able to choose the doctor, as we have been doing, so staying with "future medical" wouldn't help either. We haven't received their revised offer with the prescriptions so we will wait to see what that is. I called a lawyer's office soon after we got the first offer, and no one ever called back, so I figured they weren't that interested. Your letter made me think I should try again (another lawyer obviously). We are only getting a small amount up front, and payments for life. How would a lawyer get 10% of that? The insurance company figured out a life expectancy of 20 years, so gave us a total estimated. If we had to pay the attorney 10% of that, it would be more than we are getting up front!
    Sunny

     
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