Some individuals are “dual eligible,” meaning they qualify for both Medicaid and Medicare. In certain cases, a Medicare set-aside/special needs trust or pooled trust sub-account may be necessary to preserve the client’s dual eligibility. Medicare set-asides (MSAs) are devices used to preserve future Medicare eligibility. Currently, the use of set-asides in liability settlements is at best a grey area. However, in an abundance of caution, it may be prudent to consider setting one up when the injury victim is a Medicare beneficiary or reasonably expected to become Medicare eligible within 30 months. A special needs trust (SNT) or pooled special needs trust is appropriate for clients receiving Supplemental Security Income (SSI) or Medicaid benefits, or both. Federal law allows the creation of either an SNT or a pooled trust to preserve eligibility for needs-based benefits, such as SSI and Medicaid, after settlement of a personal injury claim.
Dual eligibility is not extremely common, but there is a subset of the injury population who will fall into this category. It is vitally important for the for the personal injury practitioner to understand who qualifies for both Medicaid and Medicare to ensure that the injury victim’s benefits are adequately protected. According to the definition of the Centers of Medicare and Medicaid Services (CMS), dually eligible clients are those who qualify for Medicare Part A Part B, or both, and who qualify for Medicaid programs as well. Medicare coverage can be obtained prior to age 65 if an injury victim 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 itself takes five months and includes the month of receipt, plus one month).
Medicare Part A provides inpatient hospital care, acute hospital care and limited nursing home care. Physician care in the hospital is also covered by Part A. There are no premiums to be paid for Medicare Part A if an individual has enough work credits (“qualifying quarters”). However, an individual can pay for the coverage if she does not have sufficient work credits. Medicare Part B covers outpatient medical services, physician services outside the hospital and other miscellaneous services not covered by Part A. Medicare Part B recipients pay a monthly premium that is often deducted from the recipient’s Social Security check, and the Part B premium increases for those with more income.
Some Medicare beneficiaries have so little income or assets that they also qualify for state programs through Medicaid that pay for certain out-of-pocket expenses not covered by Medicare. Injury victims who qualify for Medicaid may be entitled to several programs that help with expenses not covered by Medicare. In addition, state Medicaid programs cover services that Medicare does not pay for at all. . For example, Medicare does not cover nursing home care beyond 100 days, but Medicaid does for those who qualify.
The programs that cover Medicare's out-of-pocket expenses provide limited Medicaid benefits to those who qualify. Through these programs, Medicaid will pay Medicare premiums, co-payments and deductibles within prescribed limits. There are two programs: Qualified Medicare Beneficiaries (QMB) and Special Low-Income Medicare Beneficiary (SLMB). The QMB program pays for the recipient's Medicare premiums (Parts A and B), Medicare deductibles and Medicare coinsurance within the prescribed limits. QMB recipients also automatically qualify for extra help with the Medicare Part D prescription drug plan costs. The income and asset caps are higher than the normal SSI/Medicaid qualification limits. (Resources must be at or below twice the standard allowed under the SSI program and income must be at or below 100 percent of the Federal Poverty Level.)
The SLMB program pays only for premiums for Part B Medicare benefits, although SLMB recipients also automatically qualify for extra help with Medicare Part D prescription drug plan costs. Again, the income and asset caps are higher than the normal SSI/Medicaid qualification limits. (Resources must be at or below twice the standard allowed under the SSI program and income can exceed the QMB level but must be less than 120 percent of the Federal Poverty Level.)
To learn more about dual eligibility visit: http://www.cms.hhs.gov/DualEligible/