It’s a crazy world and people get hurt constantly. Car accidents, assaults and other catastrophes hurt people physically and emotionally but they don’t have to hurt financially on top of everything else.. The Affordable Care Act has removed lifetime limits on benefits and makes it illegal to deny people based on a pre-existing condition, like disabilities. As such, we are advising our colleagues and other lawyers to brush up on some of the specifics, especially now since the current enrollment period ends in February, and how the Act may impact their clients.
For example, our client Mr. Williams was a promising high school football player until his football career came to a devastating halt when he was shot nine times in his right leg. His 13-year-old sister called to tell him that a group of men were harassing her so he came to protect her. The men dispersed but one of the assailants shot Williams as he turned into a hallway in his building. He lost 40 lbs of blood, but he survived the encounter.
Williams woke up in the hospital 11 days later, happy to be alive but distraught by the realization that his leg was amputated and he would never walk again, much less play football. He was paralyzed from the waist down and spent several months in the hospital recuperating and receiving physical therapy.
In 2007, he was enrolled in New York State Medicaid, a “needs based” program that insures anyone below a certain income and asset threshold. However, his seven-figure settlement from his assault would have disqualified him from Medicaid, so we would have had to create a Special Needs Trust to oversee the funds. A Special Needs Trust allows a personal injury victim to receive a settlement without losing out on public benefits. The settlement money can also be used to pay for things that Medicaid does not cover, like extra therapy or rehabilitation.
Using the Affordable Care Act exchange, we were able to enroll Mr. Williams in a private plan health insurance plan from United Healthcare with no deductible, which provided for better health care and means that Williams no longer needs the Special Needs Trust which had a number of drawbacks in addition to adding an extra barrier to his money.
Federal law mandates that after the death of the beneficiary, any funds remaining in the trust must be used to repay Medicaid for all costs incurred while the trust was active. After Medicaid is reimbursed, the remaining funds can be passed on to the family of the beneficiary. Private insurance does not have this stipulation so the entirety of the settlement can go to the beneficiary’s family in the event of his or her death.
At ESS we help our clients assess their needs and figure out how to best deal with their situation. Many people are often caught between a rock and a hard place when it comes to dealing with settlements and insurance. We help our clients figure out how to receive the care they need to sustain them while at the same time be able to support their financial needs.
How else has the Affordable Care Act affected your clients? Are there other significant implications of the Act on settlements that you are aware of? Please share your thoughts with us.