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How does your Workers’ Compensation Case effect your Medicare Benefits?

By Steven A. Edelman, Attorney, (314) 631-6777, Ext. 14

When a worker suffers a work injury, they may not consider the effect that their workers’ compensation case has on their Medicare benefits. Medicare is primarily relevant to a workers’ compensation case involving two situations: (1) Medicare Conditional Payments and (2) Medicare Set Aside (MSA)

Why would an Injured worker be receiving Medicare Benefits at the same time as their workers’ compensation case?

  1. Some injured workers qualify by age to receive social security retirement benefits and Medicare benefits.
  2. In the most serious of work injuries, an injured worker may find that they are unable to return to work at the employer where they suffered their work injury. Additionally, the worker can not maintain employment at any job in the gainful marketplace due to their continued disability from the work injury. If the injured worker can not return to work at any job, then they may apply for social security disability (SSDI). If approved for SSDI, within a set time, the injured worker will become eligible to receive Medicare benefits and or receive Medicare benefits.

Medicare’s Interest in a Worker’s Compensation Case:

When an injured worker is eligible to receive Medicare benefits or is already receiving Medicare benefits, then Medicare’s interest must be considered when the injured worker settles their workers’ compensation case. The mechanism to protect Medicare’s interest in a workers’ compensation settlement is by drafting a written document called a Medicare Set Aside (MSA). Additionally, a Medicare Conditional Payment search must be completed to confirm if any medical bills related to the work injury were paid by Medicare.

What is a Workers’ Compensation Medicare Set Aside (WCMSA) also known as a Medicare Set Aside (MSA)?: It is a written document typically prepared by a third party company hired by the employer/insurer for the purpose of calculating the amount of money that is “set aside” to pay for future medical treatment solely for the injured workers’ injured suffered at work. Once the MSA money is exhausted, then an accounting is given to Medicare, and Medicare will then pay for the cost of future medical treatment related to the work injury.

  1. A MSA must be submitted to Medicare for Medicare’s review and approval. If Medicare approves the MSA, then the settlement may proceed forward. If Medicare does not approve the MSA, then the MSA must be recalculated and resubmitted to Medicare for approval.
  2. Once the MSA is approved by Medicare, and the workers’ compensation case is settled, the MSA money deposited by the employer/insurer into a bank account. The MSA money is typically professionally administered by a third party company paid for by the employer/insurer.
  3. After settlement of the workers’ compensation case, the professional administrator of the MSA account will then pay the medical bills for the injured worker that are related solely to medical treatment for the work injury. The MSA administrator will only pay the medical provider the amount of the medical bill that Medicare would pay per the Medicare guidelines. The balance of the medical bill is not collectible against the injured worker.

In order to comply with Section 1862(b) of the Social Security Act, Medicare is not permitted to pay for medical items or services, including prescription drug expenses, related to the workers’ compensation claim until the approved WMSA amount is appropriately exhausted (“properly spent”) on related medical care. See also: https://www.hhs.gov/guidance/document/cms-attorney-services#:~:text=%C2%A71395y(b)(2,policy%20or%20plan%20(including%20a

Important: Medicare’s interest is always considered in every workers’ compensation case. However, Medicare will only review Medicare Set Asides (MSA) in two situations:

  1. The injured worker is Medicare beneficiary and the workers’ compensation settlement is greater than $25,000 AND
  2. The injured worker “has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00” See also Medicare’s website website regarding Medicare Set Asides (MSA) and workers’ compensation benefits.

See Also Medicare’s website: https://www.cms.gov/medicare/coordination-benefits-recovery/workers-comp-set-aside-arrangements

Failure to perform a MSA and obtain approval by Medicare may result in loss Medicare benefits.

Medicare Conditional Payments:

Medicare Conditional Payments: What are they? Medicare conditional payments are medical bills paid for by Medicare for the work injury, which are conditioned on Medicare being repaid. If an injured worker is a Medicare beneficiary, it is necessary for the parties to perform a Medicare conditional payment search. This is performed by writing to Medicare to confirm if Medicare paid for any medical bills related to medical treatment for the work injury. Any medical bills paid by Medicare must be repaid to Medicare, and as part of the the workers’ compensation settlement, the employer/insurer must assume, defend, indemnify and hold harmless the injured work for any Medicare conditional payments.

If you’ve been injured at work, then please immediately contact our law firm, and one of our skilled attorneys will be happy to discuss your rights and benefits under workers’ compensation law. Call us for a free consultation: 314-631-6777, Ext. 14

Steven A. Edelman, Attorney

Illinois Workers’ Compensation, Temporary Total Disability (TTD) Explained

Temporary Total Disability (TTD)

Illinois Workers’ Compensation

Temporary Total Disability (TTD) is a check that you receive each week that you miss work because of the work injury either because (1)  The doctor takes you off work completely due to the work injury or (2) The doctor placed you on light duty work work restrictions, and the employer can not accommodate light duty work, and therefore you are off work. 

Your TTD check is equal to 66.67% of your gross average weekly wage. The gross average weekly wage is based on the average of your gross weekly wages for the 52 weeks preceding your date of injury. TTD for  governed by the law under 820 ILCS 305/8(b)

Common Problems with Temporary Total Disability (TTD) payments:

  1. The Employer pays the incorrect amount of temporary total disability (TTD).
  1. The Employer refuses to pay TTD despite the doctor placing you off work.
  1. The injured worker is on light duty work restrictions per the order of treating doctor. The employer then offers light duty work but with unreasonable requirements. For example, the offer of light duty work is at a location that is hours away, or out of state from the employee’s original assigned work location. The employer then refuses to pay TTD based on the offer of light duty work because the employee cannot reasonably travel to the light duty work. 
  1. The injured worker is on light duty restrictions per the order of their treating doctor. The employer then offers light duty work within the doctor’s accommodations but simultaneously tells the injured worker that they must perform additional full duty work outside of the doctor’s light duty restrictions. When the employee cannot do this full duty work, the employer sends the injured worker home. The employer then states that the employee refused light duty work, and therefore denies payment of TTD
  2. The Employer mails your TTD check to the employer’s address instead of mailing TTD directly to the injured worker. Mailing TTD to the employer creates unnecessary burden on the injured worker to travel to the employer to pick up their TTD check.

It is important that you immediately contact our law office to discuss your temporary total disability (TTD) benefits. We protect your rights and ensure that the employer pays you your benefits while you recover from your work injury. 

If you’ve been injured at work, then please immediately contact our law firm, and one of our skilled attorneys will be happy to discuss your rights and benefits under Illinois workers’ compensation law. Call us for a free consultation: 314-631-6777

Steven A. Edelman, Attorney

Illinois Workers’ Compensation; Medical Treatment and Choice of Medical Provider Explained

Illinois Workers’ Compensation

Medical Treatment Explained in Illinois Workers’ Compensation Cases

The First Major Benefit under Illinois Workers’ Compensation Law: The first Major Benefit under the Illinois Workers’ Compensation Act is medical treatment paid for by the employer/workers’ compensation insurance company per the law 820 ILCS 305/8(a). 

Under Illinois workers’ compensation law, an injured worker has the right by law to choose two medical providers and the referrals from each of these two chosen providers are paid for by the employer/workers’ compensation insurer. The law specifically states that:

“[T]he employer’s liability to pay for such medical services selected by the employee shall be limited to:        (1) all first aid and emergency treatment; plus        
(2) all medical, surgical and hospital services

provided by the physician, surgeon or hospital initially chosen by the employee or by any other physician, consultant, expert, institution or other provider of services recommended by said initial service provider or any subsequent provider of medical services in the chain of referrals from said initial service provider; plus
        (3) all medical, surgical and hospital services

 provided by any second physician, surgeon or hospital subsequently chosen by the employee or by any other physician, consultant, expert, institution or other provider of services recommended by said second service provider or any subsequent provider of medical services in the chain of referrals from said second service provider. Thereafter the employer shall select and pay for all necessary medical, surgical and hospital treatment and the employee may not select a provider of medical services at the employer’s expense unless the employer agrees to such selection. At any time the employee may obtain any medical treatment he desires at his own expense.”
820 ILCS 305/8

Example:

The following is one example of facts of how an injured worker can choose his doctor in an Illinois workers’ compensation case. 

First Choice of Medical Provider:

  1. You suffer injury to your back at work.  (1) You then present to the employer’s recommended doctor, or (2) You choose your own medical provider and receive medical treatment. Whether you receive medical treatment from the employer’s recommended medical provider or from your chosen doctor, this first medical providers is designated as your first choice of medical provider, i.e. “first medical provider” under Illinois law. 
  1. Therefore, the Illinois workers’ compensation insurer will pay for this initial primary care medical provider and any subsequent medical treatment referred by them, which is considered the chain of medical treatment. 
  1. The first medical provider then refers you for a MRI of your back to be performed at a hospital near you. The MRI reveals a herniated disc in your lumbar spine. The workers’ compensation insurer must pay for this MRI as it was recommended by your initial primary care medical provider.
  1. Based on the results of the MRI, the initial primary care doctor then refers you to a specialist orthopedic spine doctor. Again, the workers’ compensation must pay for you to see the orthopedic spine doctor because this specialist was recommended by your first medical provider.
  1. The orthopedic doctor prescribes you an injection in your lower back and some physical therapy that you complete. The injection and physical therapy temporarily relieve your symptoms, but a short time later all your symptoms return. 
  1. The orthopedic doctor then recommends no further medical treatment despite your continuing symptoms and releases you from medical treatment.

Second Choice of Medical Provider:

  1. You then seek another opinion from a second orthopedic spine specialist, i.e. the  “Second medical Provider.” This second orthopedic doctor is then considered your second choice of medical provider. Therefore, the workers’ compensation insurer must pay your medical bills for you to see this second orthopedic doctor. 
  1. The second medical provider reviews your back MRI and prescribes you another three week session of physical therapy at a new physical therapy location. The insurer must pay for this physical therapy because it was recommended by your second chosen medical provider.
  1. After you complete physical therapy, the second medical provider recommends back surgery to fix your back. Again, the insurer must pay for this surgery because it was recommended by your second chosen doctor. 
  1. If you then decide that you do not want the surgery and decide that you want to obtain a second opinion from another doctor, any choice of doctor after the two above choices will then be chosen by the employer/insurer.  

It is important that you immediately contact our law office to discuss your two choices of doctors. We protect your rights and ensure that the employer pays for your medical treatment for the doctor that you have chosen. 

If you’ve been injured at work and the employer is not providing you medical treatment or the employer and workers’ compensation insurer have unjustifiably denied you medical treatment, then please immediately contact our law firm at 314-631-6777.

Steven A. Edelman, Attorney