NC Workers’ Comp & SSDI: 2 Benefit System Puzzle Pieces That Don’t Always Fit Together Easily Part II

In Part I of this series, we discussed requirements/qualifications for benefits under each system and the “offset.” Now, we will pick up the conversation and discuss other considerations.

While in theory, it would seem common sense that it is better to draw benefits from two systems than one, there is another catch. 24 months after qualifying for social security disability, the person also qualifies for Medicare benefits. Naturally, Medicare doesn’t want to pay for any medical charges that might be related to a person’s work injury. That is where the Medicare Set Aside comes in. Medicare Set Asides can make workers’ compensation cases difficult if not impossible to settle, thus the idea that drawing benefits from two systems simultaneously is not always better. Medicare Set Asides are where the Centers for Medicare and Medicaid Services (CMS) tell the parties in a workers’ compensation case how much money the defendants in the case must pay into a separate account to be used for the injured worker’s injury-related medical care (so hopefully Medicare doesn’t have to pay for it). The problem is they often extraordinarily, overestimate the amount that will be required for future medical treatment. That is why Medicare Set Asides can make settling workers’ compensation claims challenging.

The language on the CMS website seems so warm and fuzzy but any seasoned attorney can tell you it’s the old wolf in sheep’s clothing scenario. The website says that there is really no requirement at all to ever submit a Medicare Set Aside to them for review and approval, though it is recommended and they specify two scenarios for review: 1) someone who is already a Medicare beneficiary whose workers’ compensation settlement is greater than $25,000.00 and 2) someone who isn’t even a Medicare beneficiary yet but who has a reasonable expectation of becoming one within 30 months and whose settlement is greater than $250,000.00. Medicare Set Asides make two types of workers’ compensation cases most difficult to settle: 1) the injured worker is also a social security disability claimant and already Medicare eligible, and 2) the injured worker who has substantial injuries who has applied for social security disability whether or not they’ve yet been approved. Though the language from CMS doesn’t seem like a mandate, to ignore it, is at everyone’s peril. It is particularly dangerous for injured workers’ to treat it as discretionary. If you fall into either of the two categories above; do not have an approved set aside and look to Medicare to cover any injury-related medical expenses, they will likely refuse and then you may have no way to pay medical bills. On the contrary, if a set aside is properly submitted, and the funds are properly depleted, Medicare will cover even injury-related bills.

Either system, North Carolina Workers’ Compensation Law or Social Security Disability, on its own can be complicated and certainly together, they are full of complexities and challenges. These can be managed and an experienced attorney can help you successfully navigate the intersection between these two systems of benefits. Consult a qualified attorney to ensure you maximize the benefits that are available to you and to protect your interests.