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Achieving Compliance: Taking Medicaid & Medicare’s Interests Into Account Florida State Association of Rehabilitation Nurses 36th Annual Educational Conference.

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Presentation on theme: "Achieving Compliance: Taking Medicaid & Medicare’s Interests Into Account Florida State Association of Rehabilitation Nurses 36th Annual Educational Conference."— Presentation transcript:

1 Achieving Compliance: Taking Medicaid & Medicare’s Interests Into Account Florida State Association of Rehabilitation Nurses 36th Annual Educational Conference Orlando, Florida May 9, 2012

2 NIMME Conferences New Orleans Feb San Diego Apr 8-9 Boston June Chicago Sep 9-10

3 3 Learning Objectives Appreciate differences between Supplemental Security Income and Disability Insurance Benefits. Become aware of differences between Medicaid and Medicare eligibility, coverage, and benefits. Learn how to protect eligibility for SSI and Medicaid despite receipt of judgment or settlement award. Understand when to consider Medicare’s interests. Know how to appropriately take Medicare’s past and future interests into account when settling a work comp, auto, or liability matter.

4 The Problem

5 5 Supplemental Security Income 8 Million Americans Receiving SSI Totaling $54 Billion

6 6 Medicaid 58 Million Americans Receiving Medicaid Totaling $466 Billion

7 7 Old Age Insurance Benefits 38 Million Americans Receiving Old Age Benefits Totaling $462 billion

8 8 Survivors Insurance Benefits 7 Million Americans Receiving Survivors Benefits Totaling $84 Billion

9 9 Disability Insurance Benefits 11 Million Americans Receiving Disability Benefits Totaling $120 Billion

10 10 Medicare 48 Million Americans Receiving Medicare Totaling $523 Billion

11 11 61 Million Americans & $1.8 Trillion $54 billion – SSI $466 billion – Medicaid $462 billion – Retirement $84 billion – Survivors $120 billion – Disability $523 billion - Medicare

12 The SSI and Medicaid Solution

13 13 Supplemental Security Income Aged or Disabled Limited Income Limited Resources

14 14 Medicaid Federally Funded, State Run Aged or Disabled Limited Income/Resources

15 15 Special Needs Trusts Irrevocable Trusts For Disabled’s Benefit Only Penalty Period

16 16 Types of Special Needs Trusts Third Party Special Needs Trust Disability Special Needs Trust Pooled Special Needs Trust

17 The SSD and Medicare Solution

18 18 Social Security Disability Insured Status Family Members Eligible Medicare

19 19 Medicare Secondary Payer Act Primary Payer Always Responsible Medicare is Secondary Payer Must Always Take Medicare’s Interests Into Account

20 20 Taking Medicare’s Interests Into Account Mandatory Insurer Reporting Conditional Payment Resolution Medicare Set Asides Allocations, Approvals, and Administration

21 21 MSP Contractor Work Load Post Mandatory Insurer Reporting MSP Contractor Workload Statistics MSP Contractor Workload Percentage increase, 2008 to 2011 NGHP MSP situations voluntarily reported to the Coordination of Benefits Contractor 141,890185,085357,747392, NGHP cases established by the MSP Recovery Contractor238,293260,912413,090480, Workers’ Compensation Medicare Set-Aside Arrangement proposals submitted to the Workers’ Compensation Review Contractor 20,25524,20326,29628,84742 Total400,438470,200797,133901,289125

22 22 MSP Contractor Payments Post Mandatory Insurer Reporting MSP Contractor Payment Statistics MSP Contractor Payments Payments Percentage increase, 2008 to 2011 NGHP MSP Coordination of Benefits Contractor $40,358,460$41,794,506$47,171,893$41,999,9964 NGHP MSP Recovery Contractor$42,014,107$63,070,146$53,205,744$58,130,22938 NGHP Workers’ Compensation Review Contractor $3,817,289$5,264,402$4,986,204$6,715,62076 Total$86,189,856$110,129,054$105,363,841$106,845,84524

23 23 MSP Savings Post Mandatory Insurer Reporting MSP Situation Saving Statistics MSP Situation Savings Percentage increase, 2008 to 2011 Workers’ Compensation$136,907,844$107,201,462$169,960,944$142,736,0394 No Fault Insurance$258,728,298$248,181,610$326,282,034$271,117,9415 Liability Insurance$341,702,138$323,768,272$424,568,902$447,889,97831 Total MSP Situation Savings $737,338,280$679,151,344$920,811,880$861,743,95917 Total Approved WCMSA Amounts $905,202,404$1,125,261,415$1,443,739,397$1,102,662,41422 Total$1,642,540,684$1,804,412,759$2,364,551,277$1,964,406,37317

24 24 Mandatory Insurer Reporting ORM Starting 1/1/11 TPOC Starting 1/1/12 Settlements/Awards >$5,000

25 25 Conditional Payment Resolution Lien from DOA to DOS Primary Payer Responsibility CP Requests/Final Demand

26 26 Medicare Set Asides Current Medicare Beneficiaries Eligible Within 30 Months of DOS No Reasonable Anticipation

27 27 MSA Process Allocation Approval Administration

28 28 MSA Allocation Future Medical Needs Appropriate Fee Schedule Life Expectancy

29 29 MSA Approval CMS Regional Offices MSA Allocation Medical/Legal Documentation

30 30 MSA Administration Self Administration Self Administration Support Professional Administration

31 31 G&L Services –Mandatory Insurer Compliance Services –Conditional Payment Resolution Services –Medicare Set Aside Allocation Services –Future Medical Costs Projection Services –Post Settlement Account Administration –Life Care Planning Services –Medical Case Management Services –Prescription Drug Services

32 32 G&L Tools –GL-Medicare Risk Assessment –GL-Search –GL-Code –GL-Professional Administration Quote –GL-Resources & Forms –GL-Industry News Bulletin –www.themedicarecomplianceblog.com

33 33 Social Media LinkedIn –Medicare and Medicaid Compliance Group –Florida Workers’ Compensation Group –Social Security Benefits Group –Hispanic Issues and Demographics Group –MSA and SNT Administration Group (soon) Twitter Facebook

34 34 Thank You! Rafael Gonzalez Director of Medicare Compliance and Post-Settlement Administration Gould & Lamb, LLC 101 Riverfront Blvd., Suite 100 Bradenton, Florida X1307


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