Additional Services Overview
In addition to the case management and bill review services at Brown, we offer the following programs to assist you in managing your claims and containing your costs.
A Medicare Set-Aside (MSA) is required in the settlement of any Workers’ Compensation case in which future medical benefits are being closed and in which the injured worker is, at the time of settlement, eligible for Medicare benefits.
If your Claimant is a Medicare beneficiary or there is a "reasonable expectation" they will become a beneficiary, they will need a Medicare Set-Asides done prior to him/her being able to settle their claim.
A Medicare Set-Asides may be submitted to the Centers for Medicare & Medicaid Services (CMS) for review in the following situations:
The Claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or
The claimant 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 lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.00.
An individual has a "reasonable expectation" of Medicare enrollment if any of the following situations apply:
The individual has applied for Social Security Disability Benefits
The individual has been denied Social Security Disability Benefits but anticipates appealing that decision
The individual is in the process of appealing and/or re-filing for Social Security Disability Benefits
The individual is 62 years and 6 months old (i.e., may be eligible for Medicare based upon his/her age within 30 months); or
The individual has an End Stage Renal Disease (ESRD) condition but does not yet qualify for Medicare based upon ESRD.
To assist our customers in meeting these obligations, Brown Rehabilitation Management’s Medicare Set-Asides Program determines the appropriate set-aside amount based on an expert analysis of the condition, current treatment, projected future treatment, and life expectancy of an individual. Our highly trained staff is then able to secure Medicare approval through a Medicare Set-Asides Proposal submitted to the Centers for Medicare and Medicaid Services (CMS).
What is needed to complete a Medicare Set-Asides Allocation?
Medical payout logs and Indemnity payout logs for the lifetime of the claim.
Pharmacy payout logs for the most recent two years.
Social Security Disability eligibility status
Medicare eligibility status and date of entitlement
Medicare number (HICN)
Last 2 years of medical reports from all treating sources, including IMEs, physician reports, hospital reports, discharge summaries, therapy reports, home health records and case management reports*
Any medical documentation of MMI, impairment ratings and extent of disability
Rated Age, if applicable
List of any denied body parts, and documentation from the insurance carrier or attorney supporting the fact that the part(s) have been denied
Proof of Representation, if applicable
*The most recent two years of payout logs and medical documentation will not necessarily be the last two calendar years!
Disability, under Social Security, is based upon the claimant’s inability to work. Claimants are considered “disabled” if they are unable to do any kind of work for which they are suited, their disability is expected to last for one year, or their disability is expected to result in death.
To qualify for benefits, the claimant must have first worked in jobs covered by Social Security for a set number of quarters, which varies depending upon the claimant’s age at the time of disability. The claimant must also have a medical condition which can be categorized as having met Social Security’s definition of disability.
Once a claimant is awarded benefits, the benefits usually continue until they are able to work again on a regular basis. In general, SSDI beneficiaries under the age of 65, may also qualify for Medicare following a 24-month waiting period following the date that they become a SSDI beneficiary.
Pursuing SSDI benefits can be a confusing and overwhelming process for claimants. Brown Rehabilitation Management can assist in simplifying the application process by offering the following:
We will educate the claimant regarding program benefits, obtain proper authorizations, gather pertinent medical documentation, complete the application for Social Security Disability, forward the appropriate application materials to Social Security for review, and conduct follow up with the Social Security Administration until a decision regarding benefit eligibility has been determined.