Benefits Advisory

Benefits Advisory & Coordination of Benefits

Ametros provides subject matter expertise and consultation on federal and state benefits for beneficiaries of worker’s compensation and liability settlements. If you have a question about preserving government benefits, how they interact or just want a second opinion on your planned course of action, please do not hesitate to contact us. Whether you have a Medicare Set Aside, other medical funds or have a complex settlement that needs full consultation and guidance through the process, we are here to help.

The list below is not exhaustive, but is illustrative of the benefits we know well. If you have questions about benefits, coverage or how to preserve programs,  we can help. Often times in complex settlements, a beneficiary, injured party or individual will have the need to retain government benefits, but also concerns about losing them if their case is not handled right. We can help simplify the explanation of what to do. Each case is unique, and we do not apply a cookie cutter approach to our advisory. Each beneficiary is special. Medicare (Parts A,B, or D), Medicaid, Social Security Disability Income(SSDI), Supplemental Security Income (SSI), Veterans Healthcare, Veterans Compensation & Disability, Supplemental Nutrition Assistance Program (SNAP) / EBT (food stamps), Medicare Set-Aside (MSA), Medigap, Medicare Advantage (also known as Medicare Part C), Consolidated Omnibus Budget Reconciliation Act (COBRA), Institutional Care Program (Long Term Nursing Home Care), Medically Needy Program, MEDS-ADProtected Medicaid, Home or Community Based Medicaid Waiver Programs, Optional State Supplementation, Home Care for Elderly and Disabled (HCE/DA), MRMIP (CA Only).

Ametros can help with the following services:

  • Bill Review and Claims processing to make sure the beneficiary is being billed at the correct fee schedule (or better)
  • Access to discounts for Providers, DMEPOS and Prescription Drug networks
  • Coordination of Benefits – ensure secondary insurance and all entities in the process address their payment obligations properly
  • Compliance reporting. In many cases, disbursement of medical funds must be reported to CMS for MSAs and per MSP regulations. We have both full and self-reporting tools for you

Part A – Explanation of Benefits

  • Benefits Entitled to or benefits denied
  • How your benefits interact, who pays first and when based on your state
  • Special circumstances
  • Calculations for benefits offset (i.e. SSDI and Lump Sum)

Part B – Best Practices for beneficiaries with settlements or who are about to settle

  • How to preserve your benefits
  • What will impair your benefits if you settle without proper planning
  • Common mistakes

Part C – Basic Budgeting for your post-settlement needs

  • How much you need based on current benefits and needs
  • Recurring costs and one off large items (i.e. home or car)

Part D – How Ametros can help

  • What is a special needs trust?
  • Full trust administration
  • What can I purchase and what is a sole benefit rule?

 

Mike and his wife were involved in a motorcycle accident.  Mike, 26, was a law enforcement officer who sustained significant injuries, including the double amputation of legs, amputation of his right hand, and abdominal injuries resulting in a colostomy, to name a few. Post-accident, Mike received Medicaid and SSI until he would be eligible for disability benefits.  The insurance policy maxed out at $100,000, in which Mike received $60,000. If Mike received any funds over the $2,000 resource limit, he would lose his means-tested benefits. Mike’s $60,000 was placed into a Special Needs Trust to preserve his Medicaid benefits, but also provide for other needs not covered by government benefits. (A future medical-malpractice case also was placed into the SNT for Mike’s sole benefit.) If Mike had received the $60,000 directly or mishandled it in the process, his medical benefits and other government assistance could have been jeopardized, severely impacting his future care and comfort. If you are an injured party, a concerned family member or a professional advisor and you encounter a situation like this and need help navigating the process, please contact us for a consultation.

Questions?

1. Download the coordination of benefits form here

2. Email the completed form to [email protected]

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Click on the state for links to Medicaid and Benefits website.

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