Some individuals are dual eligible. In plain English, this means they qualify for both Medicaid and Medicare. In certain cases, a Medicare Set Aside/Pooled Trust Sub-Account may be necessary to preserve the dual eligibility.
According to CMS:
“Dual eligibles are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit. The Medicare Program (Title XVIII of the Social Security Act) provides hospital insurance, also known as Part A coverage, and supplementary medical insurance, also known as Part B coverage. Coverage for Part A is automatic for people age 65 or older (and for certain disabled persons) who have insured status under Social Security or Railroad Retirement. Most people don’t pay a monthly premium for Part A. Coverage for Part A may be purchased by individuals who do not have insured status through the payment of monthly Part A premiums. Coverage for Part B also requires payment of monthly premiums.
Did You Know?
People with Medicare who have limited income and resources may get help paying for their out-of-pocket medical expenses from their state Medicaid program.
There are various benefits available to “dual eligibles” who are entitled to Medicare and are eligible for some type of Medicaid benefit. These benefits are sometimes also called “Medicare Savings Programs” (MSP).
For people who are eligible for full Medicaid coverage, the Medicaid program supplements Medicare coverage by providing services and supplies that are available under their states Medicaid program. Services that are covered by both programs will be paid first by Medicare and the difference by Medicaid, up to the states payment limit. Medicaid also covers additional services (e.g., nursing facility care beyond the 100 day limit covered by Medicare, prescription drugs, eyeglasses, and hearing aids).
Limited Medicaid benefits are also available to pay for out-of-pocket Medicare cost-sharing expenses for certain other Medicare beneficiaries. The Medicaid program will assume their Medicare payment liability if they qualify. Qualified Medicare Beneficiaries (QMBs), with resources at or below twice the standard allowed under the Supplemental Security Income (SSI) program and income at or below 100% of the Federal poverty level (FPL), do not have to pay their monthly Medicare premiums, deductibles, and coinsurance. Specified Low-Income Medicare Beneficiaries (SLMBs), with resources at or below twice the standard allowed under the SSI program and income exceeding the QMB level, but less than 120% of the FPL, do not have to pay the monthly Medicare Part B premiums. Qualifying Individuals (QIs), who are not otherwise eligible for full Medicaid benefits and with resources at or below twice the standard allowed under the SSI program, will get help with their monthly Medicare Part B premiums, if their income exceeds the SLMB level, but is less than 135% of the FPL.
Individuals who were receiving Medicare due to disability, but have lost entitlement to Medicare benefits because they returned to work, may buy Medicare Part A. If the individual has income below 200% of the FPL and resources at or below twice the standard allowed under the SSI program, and they are not otherwise eligible for Medicaid benefits, they may qualify to have Medicaid pay their monthly Medicare Part A premiums as Qualified Disabled and Working Individuals (QDWIs).”
What is a Medicare Set Aside?
Medicare and Social Security Disability Income (hereinafter SSDI) benefits are not income or asset sensitive. If you meet Social Security’s definition of disability and have paid in enough quarters you can receive disability benefits without regard to your financial situation. SSDI is funded by the workforce’s contribution into FICA (social security) or self-employment taxes. Workers earn credits based on their work history and a worker must have enough credits to get SSDI benefits should they become disabled. Medicare is a federal health insurance program. Medicare entitlement commences 2 years after the date of disability under Social Security’s definition. Medicare coverage is available without regard to your finances.
If you have Medicare coverage, you have to worry about the Medicare Secondary Payer (MSP) statute. The MSP is a series of statutory provisions enacted during the 1980s as part of the Omnibus Reconciliation Act with the goal of reducing federal health care costs. The MSP provides that if a primary payer exists, Medicare only pays for medical treatment relating to an injury to the extent that the primary payer does not pay.
Did You Know?
In certain cases a Medicare Set Aside is required in order to preserve future eligibility for Medicare coverage.
A Medicare set aside (hereinafter MSA) is a tool that allows an injury victim to preserve Medicare benefits by setting aside a portion of the settlement money in a segregated account to pay for future Medicare covered. The funds in the set aside can only be used for Medicare covered expenses for your work related injury. Once the set aside account is exhausted, you get full Medicare coverage without Medicare ever looking to your remaining settlement dollars to provide for any Medicare covered health care. Medicare approves the amount to be set aside in writing and agrees to be responsible for all future expenses once the set aside funds are depleted.
If you are currently a Medicare beneficiary and you settle your case you may need an MSA. If you have a “reasonable expectation” of Medicare enrollment within 30 months of the settlement date and the total settlement amount exceeds the amount set by the Centers for Medicare and Medicaid Services then you may need an MSA. Assuming you fall into one of these two categories, you may need to establish an MSA because if you do not you could lose Medicare eligibility for your personal injury related conditions.
Why Do I Need a MSA/Pooled Trust Sub Account?
A Medicare Set Aside account is considered an available resource for purposes of needs based benefits such as SSI/Medicaid. If the Medicare Set Aside account is not set up inside a Pooled Special Need Trust Sub Account, you will lose Medicaid/SSI eligibility. Therefore, in order for someone with dual eligibility to maintain their Medicaid/SSI benefits the MSA must be put inside a Pooled Special Needs Trust. The Settlement Solutions National Pooled Trust is the first of its kind to offer this unique service.