MEDICAID
There is confusion among subrogation vendors and state agencies about whether state or federal law applies to Medicaid liens. Synergy’s Medicaid experts know the law that should be applied by Medicaid agencies collecting from third party settlements. It is our mission to hold these agencies and private insurance companies to it.
Medicaid provides need-based health insurance plans administered by the State and funded federally. Eligibility and income requirements vary by state and, sometimes, by county. Medicaid programs cover both hospital and outpatient care and may offer prescription drug discounts or benefits.
Where Medicaid has made payments for medical services related to an injury it may assert a lien against the beneficiary’s recovery under state Medicaid third party recovery laws. Synergy offers complete resolution assistance including the request for compromises, statutory reductions, or Ahlborn reductions, as applicable under State provisions.
The United States Supreme Court unanimously affirmed the decision in Arkansas Dep’t of Health & Human Services v. Ahlborn. With this holding, a state’s Medicaid department will be limited to reimbursement from only that portion of a judgment or settlement that represents payment for medical expenses. States are prohibited from seeking reimbursement for Medicaid costs from settlement proceeds that were intended to cover items other than medical expenses, such as pain and suffering and wage loss.
In the United States Supreme Court’s own words, states may not demand reimbursement from portions of the settlement allocated or allocable to nonmedical damages; instead, states are given only a priority disbursement from the medical expenses portion alone. Medicaid’s recovery rights now continue to be limited to only the portion of a Medicaid beneficiary’s tort judgment or settlement designated as payments for [past] medical care.
The Ahlborn decision was reaffirmed in 2013 by the United States Supreme Court in WOS v. EMA. Similar to Ahlborn, the Wos Court discussed when the state may not demand recovery from a portion of the settlement allocated to non-medical damages. The court stated that when “there has been a judicial finding or approval of an allocation between medical and nonmedical damages—in the form of either a jury verdict, court decree, or stipulation binding on all parties—that is the end of the matter.” “With a stipulation or judgment under this procedure, the anti-lien provision protects from state demand the portion of a beneficiary’s tort recovery that the stipulation or judgment does not attribute to medical expenses.”
As a trial lawyer, it is important to understand the underpinnings of the Ahlborn and Wos decisions so you can apply them to your State’s third-party liability recovery provisions. The important thing to remember is that these cases limit a State Medicaid agency’s recovery rights related to a third-party liability settlement. In order to reduce Medicaid liens, State specific statutes must be followed, but arguments to reduce should be based on the principles espoused in Ahlborn and Wos so that the Medicaid Liens are is reduced in proportion to the full value of damages versus what was received.
Medicaid Resources
Why is Medicaid different in every state?
Medicaid is a joint federal-state program. The federal government contributes approximately 50% to fund the program. As a result, states pay the remaining costs and are given wide discretion about whom to cover and what benefits to provide. Each state has an agency in place that manages the individual state’s program. Some states allow county and city governments to administer the program. Alternatively, other states, such as Florida, hire recovery contractors.
Can I release funds to my client before the lien has been resolved?
It is not suggested that funds be released before the liens are resolved and confirmed in writing. In cases where there may be need-based benefits such as Medicaid/SSI, the distribution of funds may affect the claimant’s eligibility. Distributing funds before a valid lien is resolved can have consequences for both attorney and client. However, in some cases, if there is a guarantee that a lien holder will not increase their lien amount, a holdback may be recommended.
Can our client lose their benefits after receiving a settlement?
If your client is receiving a need-based (low income) benefit like Medicaid or SSI, a settlement or award may impact their eligibility for benefits. In order to protect eligibility for needs-based public benefits, a special needs trust should be considered.