The changing needs in healthcare are shifting millions of Americans onto Medicare Advantage (MA) Plans. Issues arise when these people suffer workers’ compensation injuries and the Plans make payment for their medical treatment and care. Claim management team members need to understand how this affects their case.
What is a MA Plan?
In 1965, Congress created the Medicare program (Parts A and B; referred to as “Original Medicare”) to allow retired and older disabled people an opportunity to receive affordable health care insurance. Throughout the years, the demands of this segment of American society changed and so did their needs. This resulted in the creation of Medicare Part C with the passage of the Balanced Budget Act of 1997. Medicare expanded several years later with Part D and a prescription drug benefit.
Under its current scheme, Medicare eligible persons have an option for coverage. They can receive coverage under Original Medicare, or through a MA Plan. An MA Plan offers the same coverages found under Parts A and B, but has the added benefit of a prescription drug plan and additional coverage options provided through a private insurance company.
Click Link to Access Free PDF Download
“8 ‘Think Outside the Box’ Tactics to Settle Workers’ Comp Claims”
MA Plan Compliance in Work Comp
The popularity of MA Plans has a significant impact on workers’ compensation cases, as federal courts are open to allowing these plans to have similar rights of recovery as Original Medicare. Claim management teams should take note of the following issues when settling cases involving these Plans.
- Expansive Rights of Recovery. Recent case law interpretations has given MA Plans in most states expansive rights of recovery using the private cause of action provisions under the Medicare Secondary Payer Act. In Collins v. Wellcare Healthcare Plans, 2014 U.S. Dist. LEXIS 17442 (E. Dist. La. 2014), a federal district court judge not only gave MA Plans another victory, but determined that regardless of what the Plan’s contract stated, their rights of recovery could also be defined and expanded by federal law.
- Resolving MA Plan Conditional Payments. Recovery of conditional payments by Original Medicare is coordinated through the Benefits Coordination & Recovery Center (BCRC). This allows for a smooth process when resolving Original Medicare’s claims by dealing with a single entity. The BCRC does not facilitate recovery efforts for MA Plans. This can result in a complicated process as some workers’ compensation cases can involve multiple Plans.
- Medicare Set-asides for MA Plans. While a Medicare Set-aside is never required, CMS does assert a right to “future medicals” under agency interpretations of the Medicare Secondary Payer Act. If courts continue to define the rights of MA Plans as being similar or the same as Original Medicare, it goes without saying a demand for future medicals could be made by MA Plans. This could be something the industry sees in the foreseeable future given increasing demands from consumers and investors who reply on private health insurance plans to remain profitable.
Dealing with MA Plans in Your Case
Claim management teams should remember to consider the recovery rights of MA Plans when settling workers’ compensation cases. This should include adding the following best practices to their compliance efforts:
- Make early inquiry if a Medicare beneficiary also has coverage through a Medicare Advantage Plan.
- Treat Medicare Advantage Plans as you treat Medicare. Be aware of current case law interpretations regarding their rights in the jurisdiction of the settlement.
- Obtain a copy of the Plan’s policy language to determine their contractual rights of recovery if case law suggests they do not have a right of recovery under federal law.
Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a monthly basis working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: [email protected].
©2015 Amaxx LLC. All rights reserved under International Copyright Law.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.
