Category Archives: Medicaid

Workers’ Compensation Medicare Set-Aside (MSA) Not a “Countable Resource” for North Carolina Medicare Eligibility

Earlier this week, the North Carolina Court of Appeals issued an opinion that will improve the lives of many injured workers who need Medicaid assistance after sustaining a work-related injury. 

In the case of Phoebe Williford v. N.C. Dep’t of Health and Human Services and N.C. Division of Medical Assistance, the Court held that assets placed in a workers’ compensation Medicare Set-Aside account should not be considered a “countable resource” for purposes of determining a petitioner’s eligibility for North Carolina Medicaid. This opens the door for many injured workers to now apply (or re-apply) for Medicaid assistance even if they have a separate bank account containing thousands of dollars earmarked for future medical treatment. 

A workers’ compensation MSA is not a piggy bank that an injured worker can use for anything s/he wants. “The purpose of a MSA is to allocate a portion of workers’ compensation award to pay potential future medical expenses resulting from the work-related injury so that Medicare does not have to pay.” The injured worker must keep the funds separate from his/her other accounts, must maintain an accounting, and must only use the funds for future medical treatment related to his/her injuries. MSA accounts are regulated and injured workers must report to Medicare. CMS recently published a toolkit to help injured workers manage their MSAs. As you see, there are specific restrictions and requirements on how the money is used.

In the Williford case, the petitioner originally did not qualify for Medicaid because she had more than $2,000 in liquid assets (i.e. her MSA account). The issue before the Court was whether the petitioner’s MSA account, containing approximately $46,000, should be counted as a “financial resource for purposes of determining the petitioner’s eligibility for Medicaid.” 

The Court concluded that the WC MSA was not a countable resource because “…federal standards clearly establish that, in order for a given asset to be a countable resource, the asset must be legally available to the applicant without legal restriction on the applicant’s authority to use the resource for support and maintenance.” Because there are requirements governing the WC MSA, the funds were not “legally available” “without legal restriction” and not a “countable resource.” 

That said, when settling a workers’ compensation claim any other portion of the settlement (i.e. lump sum cash) would likely be considered “legally available” funds. If appropriate, a special needs trust should be considered in certain cases to avoid these funds from disqualifying a person from Medicaid.

Not Expanding Medicaid: Deadly Consequences

Today’s post comes from guest author Charlie Domer, from The Domer Law Firm.

Please take a moment to ready this story out of Pennsylvania: Study: Many Will Die if Medicaid is Not Expanded.   As part of the Affordable Care Act (“Obamacare”), an expansion of Medicaid was intended.  Medicaid essentially is the joint federal-state program to provide health insurance to low income individuals and families.   The federal government strongly encouraged this expansion by the states, by offering to pay for that expansion for many years.   Unfortunately, the US Supreme Court–in upholding the constitutionality of the bulk of Obamacare–did strike down this Medicaid expansion.  The Supreme Court decision left it up to the state’s themselves to decide whether to expand Medicaid for their residents or not.

In many Republican-led states, the decision was made to not expand Medicaid.  As seen in this article, Pennsylvania was a state that declined to expand.  Wisconsin, with Republican Governor Scott Walker, also decided not to provide this expanded Medicaid coverage to the the state’s low income individiduals.  (Check out the story here and here.) 

Now comes news that failure to expand Medicaid may actually result in increased deaths among the affected population.  The failure to have this expanded coverage, according to the study examining Pennsylvanis, will result in thousands of deaths due to individuals foregoing necessary medication, medical treatment, and preventative screening. Additionally, the expansion failure will result in “catastrophic medical expenses and tens of thousands of cases of untreated depression, diabetes and missed screening tests.”   This is a truly scary scenario–and an avoidable one.

In Wisconsin, Gov. Walker is suggesting that these individuals can now obtain health insurance throught the federal-run exchanges.  The real issue is whether these low-income individuals can truly afford the premiums and whether they actually qualify for the federal subsidies.  These lower-income individuals were the one supposed to be covered by Medicaid expansion–not by the exchanges.    Based on the Pennsylvania study, if these individuals are ineligible for Medicaid and cannot secure health insurance elsewhere, dire health consequences (or even death) loom as possibilities.