1 Workers Compensation Medicare Set-Aside (WCMSA) & Conditional Payments: Addressing Issues Before & During Mediation F. Scott Young, Esq Glenridge Drive Suite E100 Atlanta, GA
2 WORKERS COMPENSATION MEDICARE SET-ASIDES (WCMSA) AND CONDITIONAL PAYMENTS F. Scott Young, Esq. BAY Mediation & Arbitration Services, LLC Historical Overview of the Problem in a Nutshell The historical framework behind Workers Compensation Medicare Set-Asides (WCMSA), conditional payments, and future medical expenses can be boiled down to a simple question: Who should be responsible for paying Medicare benefits to a Medicare eligible individual whose medical conditions were originally the responsibility of a primary payer (i.e. workers compensation carrier)? For decades, the Medicare program has made payments on behalf of Medicare beneficiaries which arguably should have been made by primary payers, including workers compensation carriers. The initial response by the government which attempted to remedy this situation was the passage of the Medicare Secondary Payer Act (MSP). The MSP was passed in 1980 and is codified at 42 U.S.C. 1395y and 42 C.F.R The intent of the Medicare Secondary Payer Act was to reduce Medicare spending by prohibiting Medicare from making payments where another entity had a legal or contractual obligation to provide the medical treatment. The legislative intent clearly was that Medicare should always be a secondary payer if a primary payer, such as workers compensation, exists. The Medicare Secondary Payer Act does, however, allow Medicare to make conditional payments in situations where the primary payer is unknown or in those situations where the Medicare recipient requires treatment and care that is otherwise not being paid. As a result, the Medicare program has made payments for decades under these exceptions when some other entity was truly responsible. The Centers for Medicare and Medicaid Services (CMS) is an agency within the Department of Health and Human Services which is responsible for administering the Medicare program. Its primary function is to protect the financial assets of the federal government by ensuring that primary payers make payments for the injuries of claimants
3 under the workers compensation system even if those claimants are eligible for Medicare. This ensures that the federal government is not paying for work-related injuries. Despite the intent of the Legislature in enacting the Medicare Secondary Payer Act in 1980, there was no framework in place which allowed the CMS to enforce the requirements of the act. In an effort to rectify this situation, the Medicare, Medicaid and SCHIP Extension Act of 2007 was signed into law in December of that year. The 2007 Act at Section 111 amended the Medicare Secondary Payer Act to require insurers to regularly report all open claims and settlements, judgments and awards involving Medicare beneficiaries. In order to ensure compliance, the Act includes a penalty of $1, per day per claim for noncompliance. The imposition of a fine caught the attention of many primary payers. CMS released a reporting requirement start date of October 1, 2009, which date was later extended to January of As a result, all workers compensation carriers were obligated to provide their reporting as of January 2011 and into the future. The United States Government Accountability Office in its May 9, 2012 report to the Committee on Ways and Means estimated that in 2010 Medicare paid 509 billion dollars to cover medical expenses for its 47 million beneficiaries. The Congressional Budget Office estimated that these provisions for non-group health providers and group health providers would save Medicare 1.1 billion dollars over 10 years in payments that could be recovered or avoided by Medicare due to an obligation of a primary payer. The potential cost savings to the Medicare system is enormous. This paper will address issues involving Medicare Secondary Payer compliance in workers compensation cases. The primary focus will be on reporting requirements, conditional payments, workers compensation Medicare Set Aside arrangements (future payments), workers compensation Medicare Set Aside arrangements that do not require CMS approval, and practice tips for settling a workers compensation case. Reporting Requirements The catalyst for mandatory insurer reporting was a May 4, 2001 report prepared by the General Accounting Office (GAO), the investigative arm of Congress, which detailed a study that was conducted between March 2000 and March 2001 focusing on workers compensation program benefits. The report showed that workers compensation claimants often collected
4 workers compensation benefits, full Social Security Disability (SSDI) benefits or Supplemental Security Income (SSI) without any set offs. Set offs typically did not occur as the GAO determined that the Social Security Administration was typically unaware of workers compensation claims. This was costly to the Social Security Administration as it was often paying for the medical treatment of beneficiaries who were actually injured on the job. Medical expenses related to on the job injuries should have been paid by the primary payer (i.e. the workers compensation carrier). The report indicated that gathering information from workers compensation carriers about the injured workers they were paying and recording this information in a central database could have the effect of reducing the money paid out by Medicare. The GAO report stated if SSA (Social Security Administration) is unable to establish a viable voluntary WC beneficiary reporting process the Congress should consider establishing a periodic reporting requirement that provides the Federal Government with the information that identifies WC beneficiaries. U.S. General Accounting Office, Workers Compensation: Action needed to reduce payment errors in SSA disability and other programs, GAO (May 4, 2001) at 25. While it took approximately 6 years following this initial report, the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) was enacted. Section 111 of the 2007 Act requires the providers of group health plans, liability insurance (including self insurance, no fault insurance and workers compensation insurance) to determine the Medicare entitlement of all eligible claimants and report certain information about those claims to the Centers for Medicare and Medicaid Services (CMS). The purpose of the legislation is to enable CMS to determine primary versus secondary payer responsibilities so that Medicare covered items are paid by the proper entity. The legislation requires the insurer to make a determination as to whether the claimant is entitled to Medicare benefits pursuant to 42 U.S.C.S. 1395y (b)(8)(a)(i). If the claimant is Medicare entitled, the insurer must submit certain information with respect to the claimant to the Coordination of Benefits Contractor (COBC). COBC maintains a comprehensive database on all Medicare beneficiaries and oversees Section 111. Collected information includes identification of the primary payer and certain identifying information of the beneficiary. The penalty for noncompliance of the mandatory reporting requirements on the part of the insurer is $1, per claim per day.
5 This penalty is in addition to other fines that Medicare may impose if Medicare s reimbursement claim is ignored in any settlement. Responsible Reporting Entities (RRE) are those entities which must report. This includes workers compensation insurers. A Third Party Administrator or TPA is not a responsible reporting entity unless the TPA is self-insured for its own liability and/or workers compensation exposure. Likewise, the insurance carrier cannot contract away its liability to a TPA. It is the responsibility of the RRE under Section 111 to report directly to the Coordination of Benefits Coordinator (COBC) or to use a reporting agent. Reporting agents like TPAs are not held responsible for the obligations of the RRE. Therefore, if an insurer decides to use a reporting agent, it is important that the insurer confirm that reporting is occurring in a timely fashion. With the fines of $1, a day per claim, it is crucial that the Responsible Reporting Entity report all claims even if there is a possibility that certain claims may not fall under the requirements of Section 111. Typically, insurers register and set up accounts with the Coordination of Benefit Contractor. The secure website of the COBC is located at The information sought includes: Claimant s Name Claimant s Medicare Health Insurance Claim Number (HICN or SSN) Gender of Claimant Date of Incident Nature of Injury or Illness - ICD-9 codes Name and Address of the Workers Compensation Insurance Carrier Name and Address of all Legal Representatives Name of the Insured Policy and Claim Number In my practice, I have developed Interrogatories that I send to all Plaintiffs and Claimants in liability and workers compensation cases involving personal injury. These
6 Interrogatories specifically address the information sought by the COBC. This usually includes the Claimants name, Medicare or Social Security Number, date of incident and the nature and extent of the injuries. I also inquire as to whether or not there is a third-party claim. I then provide this information directly to the insurance carrier who can then provide the information pursuant to the federal law. In workers compensation claims where a hearing has not been requested and, thus, discovery is not possible, many insurance carriers send out a form letter requesting information pertaining to these reporting areas. A copy of a sample letter is attached to this paper as an Addendum. Keep in mind that the civil penalty of $1, per day for each day of noncompliance with respect to each claim is mandatory and not discretionary. To put it in perspective, each claim that is reported 90 days late carries an automatic $90, penalty. It does not take many reporting mistakes to cost a carrier a great deal of money. If a carrier has just 10 claims that were each reported 90 days late, it is facing $900, in penalties. The stiff penalties alone convince most carriers to diligently pursue their reporting requirements. Handling Conditional Payments Medicare conditional payments are payments made by Medicare on behalf of a Medicare beneficiary for medical treatment costs which should have been paid by a primary payer. Regardless of whether Medicare made these payments because the insurance claim entity was unknown or in dispute, by statute, these payments must be reimbursed to Medicare or penalties, interest and potential double damages may apply. Conditional payments are in fact the first step and most logical place for Medicare to recover funds it spent that should have been paid by a primary payer. Conditional payments are usually identified by CMS through the use of ICD-9 codes. When a carrier does its reporting under its mandatory reporting obligation, one of the areas it must report is the type of injury per the ICD-9 code. ICD-9 codes are used on most, if not all, health insurance claim forms (HICF) and are universal. ICD-9 stands for International Classification of Diseases 9 th Edition. There is a separate and distinct ICD-9 code associated with each type of injury. As a result, it is
7 important that the insurance carrier double check the ICD-9 codes to be sure that its reporting of the type of injury is accurate. Handling conditional payments under workers compensation is probably the most straight forward and simplest aspect of the workers compensation Medicare set aside and conditional payment analysis. First, a signed Release from the Claimant must be obtained in order to start the inquiry. Generic release forms are attached to this paper as Addendums. Second, a request should be made seeking the total amount of payments made by the Medicare Secondary Payer Recovery Contractor (MSPRC). Once this is processed, CMS will send out a detailed analysis of the payments Medicare has made from the date of the incident forward. It is imperative that the ICD-9 codes in this report be analyzed thoroughly to determine whether or not CMS is claiming a conditional payment for services that were not workers compensation related. For example, if a Medicare beneficiary sustained an on the job injury involving a left lower extremity and the CMS report reveals that Medicare paid for a kidney related ailment, then an exception would need to be made as to the kidney treatment. The fourth step is to assess the validity or invalidity of the ICD-9 codes and the conditional payment amounts so that a determination can be made internally by the insurance carrier as to what it believes to be the proper amount of conditional payment. The fifth step is to submit an offer of settlement to the Medicare Secondary Payer Recovery Contractor with the specific justification for the conditional payments that are not workers compensation related. This is the only appeal opportunity which now exists under the MSP Act. CMS will then issue a final demand letter and the beneficiary has 60 days in which to make payment or be subject to interest or penalties. Delinquent or unpaid debt is referred to the US Treasury Department for collection. Whoever is listed as the debtor will be notified by MSPRC through an Intent to Refer Letter, allowing 60 days to respond and resolve the debt. (Once the debt is referred to the Treasury, the parties are no longer allowed to work with MSPRC to resolve the debt.) Lastly, final settlement documents must be submitted to CMS and must include the total amount of the settlement, total amount of med pay or PIP, the amount paid by the beneficiary in attorney s fees, any additional procurement expenses in itemized format paid by the beneficiary, and the date upon which the case settled. A sample of a final settlement document which would be submitted to the Medicare Secondary Payer Recovery Contractor at the end stage of the process is attached as an Addendum.
8 Finally, one manner in which the parties can come to some pre-settlement understanding of the possible conditional payments that would be owed to Medicare is through the My Medicare website. A claimant can go to and do a search of all payments made on his behalf by Medicare from the date of accident forward. An analysis then using the ICD-9 codes should be implemented to get a rough estimate of the amounts that were charged and the amounts that Medicare actually paid. The caveat to this is that this is simply a tool for determining the estimated amount of possible conditional payment. Medicare is not bound by the information contained on that website. Workers Compensation Medicare Set-Aside Arrangements (WCMSAs) When considering whether or not a Medicare Set-Aside needs to be set up to cover future medical expenses, there are basic criteria which govern. This is by far the most difficult aspect of the MMSEA facing insurers. In general, the following questions need to be answered: (1) Does the settlement involve a medical claim? (2) Is it reasonably likely that the Claimant will have future medical expenses related to his on the job injury? (3) But for the workers compensation injury, would the Claimant s medical expenses otherwise be covered by Medicare? and (4) Is the Claimant likely to be a Medicare beneficiary when such medical expenses are incurred in the future? The Workers Compensation Medicare Set-Aside is a vehicle used to eliminate or greatly reduce Medicare s obligation to pay any medical expenses associated with the claimant s workers compensation injury. The MSA or Medicare Set-Aside Arrangement is a voluntary arrangement where a portion of the proceeds from the settlement are set aside to pay for all related future medical expenses that would otherwise be reimbursable by Medicare if Medicare were the primary payer. Under this arrangement, Medicare would not make payments for medical expenses related to the on the job injury until the Medicare Set-Aside Arrangement funds are exhausted.
9 As previously stated, the Workers Compensation Medicare Set-Aside Arrangement Review Program is voluntary. However, the vast majority of attorneys and insurance carriers continue to believe that the review program is required by MSP. Despite the fact that it is voluntary, there is still an overwhelming trend toward submission as a safe harbor. The primary is that if the MSA is submitted and approved by CMS then CMS assures that no further amounts would be required in the future. This forecloses the possibility of any future legal liabilities related to the settlement. On May 11, 2011, the Centers for Medicare and Medicaid Services issued a Memorandum setting forth criteria for eligible WCMSAs. While they reiterated that submission of the WCMSA proposal to CMS for review and approval is a recommended process, there is no absolutely statutory or regulatory provision requiring that a WCMSA proposal be submitted to CMS for review. If, however, a carrier chooses to use the WCMSA process, CMS has established policies and procedures for the submission. The memo goes on to provide that: (1) Medicare reviews certain workers compensation settlements in order to protect Medicare s interest under the Medicare Secondary Payer Statute and its implementing regulations; (2) A WCMSA meets the criteria of CMS for review when the following thresholds are met: The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000.00; or The claimant has a reasonable expectation of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount of future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250, The Memorandum makes it clear that CMS will no longer review WCMSA proposals that do not meet these thresholds. They are quick to point out that these requirements do not constitute a substantive dollar or safe harbor threshold as it remains true that Medicare beneficiaries still must consider Medicare s interest in all workers compensation cases and insure that Medicare is the secondary payer to workers compensation in such cases. A
10 couple of these eligibility requirements are fairly simple. When looking at the reasonable anticipation of Medicare eligibility requirements, CMS looks at multiple issues including: (1) Whether the individual applied for Social Security Disability; (2) Whether the individual has been denied Social Security Disability but has appealed; (3) Whether the individual is in the process of appealing or re-filing for Social Security Disability benefits; (4) Whether the individual is 62 ½ years of age and thus may be eligible for Medicare within 30 months or the individual has end stage renal disease but does not yet qualify for Medicare based upon that condition. The other threshold or eligibility requirement is the total amount of the settlement. The settlement amount includes: indemnity benefits; attorney s fees; the MSA payout amount; non-medicare allocation amounts; settlement advances; lien or conditional payments; amounts written off by the carrier; and any previous settlement awards or judgments in either liability or workers compensation claims. It is rather easy to hit the $25, threshold with most cases. Additionally, CMS looks at the actual payout amount of the MSA annuity as opposed to the cost of the annuity. For example, if an annuity has a total payout of $200, but the upfront annuity only costs $123,000.00, CMS still calculates $200, for its threshold determination. There are multiple ways in which one can calculate the MSA amount. While CMS uses a particular formula, there is no requirement that a particular methodology be used. MSA allocation reports can be drafted by specialized attorneys, nurses, doctors, pharmacists, insurance adjusters, etc. The most important aspect is to have defensible grounds for the development of the MSA amounts. MSA allocation reports have been prepared by life care planners who calculate the future costs associated with the ongoing care for the claimant. Many certified life care planners come from the vocational rehabilitation arena and implement a specific methodology. Their future cost projections are often calculated by an accountant.
11 The most important aspect of the MSA is to provide for future medical costs related to the injury. These include costs of treating physicians, costs of prescription medications and costs of functional aides and prosthetic devices. A sample spreadsheet of a Workers Compensation Medicare Set-Aside Allocation Report is attached as an Addendum. Currently, one of the overriding concerns for carriers is the cost of prescription medications which were added to the Medicare Set-Aside Allocations effective January 1, As a result, all workers compensation MSAs must consider and protect Medicare s interest when future treatment includes prescription drugs that would otherwise be reimbursable by Medicare. It is not uncommon for the costs of prescription medications to far outweigh the costs associated with medical treatment and care. In an effort to address the prescription drug issue, MSA providers and workers compensation carriers are becoming much more creative and aggressive in trying to control the costs of prescription medications. This includes implementing tools such as tapering medication usage, encouraging off label use of drugs, and requiring the use of generics rather than the use of brand name drugs. One of the most effective tools in cutting down on the future cost of prescriptions drugs is to request that the authorized treating physician identify each and every drug that has been prescribed to the claimant during the lifetime of the claim and then for he or she to identify those drugs which will not be used in the future. If tapering, off label use and generics are appropriate the physician should indicate that as well. This should be done long before medical records are submitted to an MSA provider for an allocation report. Once an allocation report is received and it includes a projection for medical treatment and prescription drugs, a decision must be made as to whether or not CMS approval will be sought before or after a settlement is reached in the case. Many workers compensation carriers are opting to submit their MSAs to CMS for approval prior to coming to a final settlement. This can be done as long as the MSA vendor is provided a general outline of possible settlement terms. In other words, will the settlement meet the thresholds to allow CMS to perform a review? The advantage of submitting the MSA to CMS before having a stipulation or settlement approved by the State Board of Workers Compensation is that if CMS issues a review letter that is far in excess of the allocation report then the carrier can elect not to settle the medical aspects of the claim.
12 It is currently taking about 150 business days, on average, for CMS to review and approve an MSA. Obviously, the carrier will have to continue to pay the claimant income benefits while waiting for CMS to review and approve an MSA. In Georgia, for example, the maximum income benefits would be $ per week, which means the carrier would end up paying an additional $15, to $20, of income benefits while waiting for CMS to approve the MSA. However, depending on the size of the initial allocation report, this may be money well spent. There have been numerous cases in which CMS has actually doubled or tripled the amounts shown in allocation reports even though the reports were issued by extremely reputable vendors. In those scenarios, had the cases been settled and approved by the State Board first, the language in the settlement documents would have required the insurance carrier to fund the additional monies necessary to protect Medicare s interest. For this reason alone most carriers are requiring CMS approval prior to seeking Board approval of the Stipulation. Fortunately, having used multiple vendors over the years for WCMSA allocation reports and CMS submissions I see little or no difference from vendor to vendor regarding the speed with which CMS approves an MSA once it is received from the vendor. The biggest difference I have seen is the amount of time it takes the vendors to provide a detailed MSA. This can vary from 10 days to a month. The insurance carrier has multiple options when it comes to funding the MSA. First, an MSA will consist of seed money which represents the amount of Medicare eligible treatment that would occur during the first year and a half to two years. The remaining amount will be the amount that would be paid out during the lifetime of the MSA. An insurance carrier can make a lump sum payment to the claimant, who places the money in an MSA account separate and apart from his own personal funds. The claimant can selfadminister those funds and has reporting requirements to the Medicare Secondary Payer Recovery Contractor. This is usually only done with settlements that require an MSA of $10, or less since it is extremely difficult to find companies who are willing to structure MSAs of less than $10, The second and more common way that MSAs are funded is through the use of an annuity. At the time the MSA allocation report is received from the MSA vendor, a structure
13 should be requested from a reputable structured settlement company. Most MSA vendors will provide a generic structure. It is important that structures are placed with highly rated annuity and life companies because if the life company goes out of business or defaults, the insurer is responsible for carrying out the remaining aspects of that settlement despite the fact that it paid for the annuity. In Georgia, there are two mechanisms for structures. One is a reinsurance agreement and the other is a qualified assignment. Both alleviate the workers compensation carrier from future exposure and pass that exposure onto the annuity company. Qualified assignments can be used in claims with dates of loss after The reinsurance agreements are good on all claims. When structuring an MSA annuity, the parties must make a determination as to whether or not the claimant will self-administer the annuity or whether it will be professionally administered. Professional administration typically runs about 10 to 15% of the cost of the annuity. The administration aspect is the annual reporting showing the amount of Medicare Set-Aside Funds that have been used for workers compensation related injuries. As a result, there is a certain amount of record keeping and yearly attestation that must take place. On October 1, 2011, a third option with regard to administration of MSAs came about. The Medicare Secondary Payer Charitable Foundation (MSPCF), a not-for-profit organization, announced that it would provide free professional Medicare Set Aside Administration nationwide for qualified beneficiaries beginning October 1, According to its press release, the foundation was created to provide much needed assistance to Medicare beneficiaries facing MSP compliance issues resulting from an insurance settlement. The Medicare Secondary Payer Charitable Foundation is independent of its sponsors and is vendor neutral. Any CMS-approved MSA over $25, from any vendor, payer, claimant or attorney will be accepted for administration subject to the terms and conditions of the master trust and joinder agreement. For more information on this program the Board of Trustees of the MSP Charitable Foundation at The best advice that I can provide any practitioner when working with the Centers for Medicare & Medicaid Services is to retain an experienced Medicare Set Aside provider. I have attached, as an Addendum to this paper, a list of MSA providers with whom I have
14 worked. This is in no means an inclusive list. Other MSA providers can be found using any search engine or by talking with other lawyers regarding companies they have used. Dealing with WCMSAs That Don t Require CMS Pre-Approval Most of this paper is focused on WCMSAs that require CMS approval because they meet the appropriate threshold. However, there are many workers compensation claims that are settled and have MSAs which do not require CMS approval. The obligation of the insurer is to protect the interests of Medicare regardless of the amount of the settlement. For this reason, many insurers are running MSAs on borderline cases simply to show that they are protecting Medicare s interest. If Medicare were to ever come back and question such a claim, the insurer would be able to show that Medicare s interest was protected in the settlement. Settlement language within the Release should also be reflective of this. Innovative Ways to Settle a Case When it comes to Workers Compensation Medicare Set-Asides and stipulated settlements, often times it is necessary to think outside the box in order to get a case settled. There is no requirement that Medicare s interest be considered if future medical is not being closed. In other words, if the insurer is willing to remain 100% liable for all future medical expenses associated with the on the job injury, then Medicare s interests are protected by the fact that they have no future exposure for any medical related to that injury. In cases where MSAs are extremely expensive (i.e. cases involving high future prescription medication costs or catastrophic injury) many carriers are settling the indemnity, permanent disability, mileage, attendant care and all aspects of the claim that would not be covered by Medicare and leaving medical open, including prescription medications. Keep in mind only those items that would be covered by Medicare need to be left open. For example, under most cases Medicare will not pay for home health services. As a result, a claim for home health services can be settled without having to consider Medicare s interest as long as the other aspects of medical that would be covered by Medicare are left open. Off-label drugs fall under the same category. In cases where medical will be left open as a means of protecting Medicare s interest, there is a growing sentiment that if a workers compensation claimant is paid a lump sum amount of money and he knows he is never going to get any additional money then he is less likely to
15 continue treating. While this is certainly not scientific, many carriers are testing this theory on cases that require extremely high dollar MSAs in order to protect Medicare s interest. Conclusion All in all, the standard is simple but the implementation of MSP is difficult. The obligation is to report claims so the Centers for Medicare and Medicaid Services (CMS) can track them and make an analysis as to whether or not there are conditional payments owed so that the government s future interests are protected in settlements which close out the primary payer s medical obligation.
16 GLOSSARY OF MEDICARE ACRONYMS AWP Average Wholesale Price CMS Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration (HCFA)) COB Coordination of Benefits Contractor DOI Date of Incident GHP Group Health Plan HICN Health Insurance Claim Number ICD-9 International Classification of Diseases, 9 th Edition MMA Medicare Modernization Act of 2003 MMSEA Medicare, Medicaid and SCHIP Enforcement Act of 2007 MSA Medicare Set-Aside MSP Medicare Secondary Payer MSPRC Medicare Secondary Payer Recovery Contractor The MSP The Medicare Secondary Payer Act of 1980 NGHP Non-Group Health Plan (liability insurance including self-insurance, no-fault insurance, and workers compensation laws and plans) RRE Responsible Reporting Entity SCHIP State Children s Health Insurance Program SSA Social Security Administration TPOC Total Payment Obligation to the Claimant WCMSA Workers Compensation Medicare Set-Aside Arrangement WCRC Workers Compensation Review Center
17 July 6, 2015 Claimant Address Dear : Re: Claimant : Employer : Date of Injury : Claim No. : Our File No. : We are investigating an accident which may have caused, or will cause, you to seek medical treatment. To assist us in investigating this matter, please provide and/or confirm the following information: Your full legal name as it appears on your Social Security card:. Your Social Security Number: - -. Your date of birth: / /. Are you currently an age based social security Beneficiary? [ ] Yes [ ] No Are you currently a social security disability income Beneficiary? [ ] Yes [ ] No Are you a Medicare Beneficiary? [ ] Yes [ ] No If yes, what is your Medicare Health Insurance Claim Number?. Signature: Date: / / After you complete this form, please return it to us in the enclosed self-addressed envelope. Thank you for your cooperation during this process. Very Truly Yours, Barrickman, Allred & Young, LLC FSY/jtl F. Scott Young
18 CONSENT TO RELEASE FORM The Privacy Act of 1974 (Public Law ) prohibits the government from revealing information from personal files without the express written permission of the person involved. Disclosure of personal records to an attorney or other representative who is acting on behalf of another person is prohibited, unless the individual to whom the record pertains has consented. I,, hereby authorize the Centers for Medicare & Medicaid Services (CMS), its agents and/or contractors to disclose, discuss, and/or release, orally or in writing, information related to my workers' compensation injury and/or settlement to the individual(s) and/or firm(s) listed below. This consent is for my current workers' compensation claim and is on an ongoing basis. An additional consent to release form will not be necessary unless or until I revoke this authorization (which must be in writing). PLEASE CHECK Claimant's Attorney (name and/or firm) Employer's Attorney (name and/or firm) Workers' Compensation Carrier (name and/or firm) Other Claimant's Signature Claimant's Mailing Address City/State/Zip Date of Injury Date Signed Social Security Number Health Insurance Claim Number (if currently entitled to Medicare)
19 Form Approved OMB No Social Security Administration Consent for Release of Information TO: Social Security Administration Name Date of Birth Social Security Number I authorize the Social Security Administration to release information or records about me to: NAME ADDRESS I want this information released because: Medicare s interests in a potential insurance settlement pursuant to the Medicare Secondary Payer Act (There may be a charge for releasing information.) Please release the following information: Social Security Number Identifying information (includes date and place of birth, parents names) Monthly Social Security benefit amount Monthly Supplemental Security Income payment amount Information about benefits/payments I received from to Information about my Medicare claim/coverage from to (specify) Medical records
20 Record(s) from my file (specify) Social Security entitlement status, date of SS entitlement or date of application if still pending, date of denial, date of appeal, status of appeal, basis for entitlement (disability or age), Medicare status, date of entitlement Other (specify) Medicare A and B. I am the individual to whom the information/record applies or that person s parent (if a minor) or legal guardian. I declare under penalty or perjury that I have examined all the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both. Signature: (Show signatures, names, and addresses of two people if signed by mark.) Date: Relationship:
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