The Interplay Between Medicare and Medicaid for Injured Workers

• Publication year: 2019
• Author: Jason D. Lazarus, J.D., LL.M., CSSC, MSSC Orlando, Florida

The Interplay Between Medicare and Medicaid for Injured Workers

Jason D. Lazarus, J.D., LL.M., CSSC, MSSC Orlando, Florida

This article discusses dual eligibility for injured workers. It addresses exactly what it is and how Medicaid (in California, Medi-Cal) coordinates with Medicare for those who are eligible for both programs. It takes a look at Medicare Set-Asides (MSAs) and Special Needs Trusts (SNPs) and techniques to preserve Medicaid and Medicare. Finally, it examines the intersection of these two public benefit preservation trusts.

Some individuals are "dual eligible," meaning they qualify for both Medicaid and Medicare. In certain cases a Medicare Set-Aside/Special Needs Trust (SNT) or pooled Special Needs Trust may be necessary to preserve the claimant's dual eligibility. A Medicare Set-Aside Trust is a device used to preserve future Medicare eligibility. An SNT or pooled Special Needs Trust is appropriate for claimants receiving Supplemental Security Income (SSI) and/or Medicaid benefits. Federal law allows creation of either an SNT or a pooled SNT to preserve eligibility for needs-based benefits, such as SSI and Medicaid, post settlement of a workers' compensation claim.

Dual Eligibility

Dual eligibility is not extremely common, but there is a subset of the injury population that will be dual eligible. Understanding who qualifies for both Medicaid and Medicare is vitally important for the workers' compensation attorney to ensure the injured worker's benefits are adequately protected. By CMS's definition, dual eligible claimants are those who qualify for Medicare Part A and/or Part B and also qualify for Medicaid programs. Medicare coverage can be obtained prior to age 65 if an injured worker qualifies for Social Security Disability Insurance (SSDI). It takes a total of 30 months for someone who is disabled to qualify for Medicare. (Medicare coverage begins 24 months after the first SSDI check is received, which takes six months including the month of receipt).

Some Medicare beneficiaries have so little income or so few assets that they also qualify for state programs through Medicaid that pay for certain out-of-pocket expenses the Medicare program does not cover. There are several programs that injured workers who qualify for Medicaid may be entitled to that help with such expenses. In addition, there are services Medicare does not pay for that state Medicaid programs can cover. For example, Medicare does not cover nursing home care beyond one...