Preview
FILED: DUTCHESS COUNTY CLERK 08/16/2023 11:03 AM INDEX NO. 2021-53794
NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023
Re r ,llur 20 l8
STATE OF NEW YORK SUPREME COURT
DUTCHESS COUNTY
JACOB ROSADO,
Plaintiff,
AFFIDAVIT OF
-against STATUS OF MEDICARE
ELIGIBILITY
DEJUAN KOONCE,
Index No. 53794-2021
Defendant.
STATE OF NEW YORK )
) SS.
COLINTY OF DUTCHESS )
JACOB ROSADO being duly sworn, deposes and says:
1 . I am the plaintiff in the above-entitled action, I am a citizerr of lUnited States], I reside at
[ , Poughkeepsie NY 12601) and my telephone number is 845- -
1.
2. I make this affidavit with full knowledge that it will be relied upon by the State of New
York, its agents, employees and representatives ("OAG") in connection with settlement of this
action against Dejuan Koonce and specifically as it relates to OAG's obligations to comply with
the reporting requirements of Section 11 1 of the Medicare, Medicaid and SCHIP Extension Act
of 2007 ("MMSEA") and the Medicare Secondary Payer Act ("MSP")'
3. I understand that a query has been / will be made pursuant to Section 111 of the
Medicare,MedicaidandSCHIPExtensionActof200T,42[JS.C. 1395(BX8)toverifl,my
current Medicare status.
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NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023
4. I hereby acknowledge and understand that, as mandated by CMS and promulgated by and
through its rules and regulations including but not limited to the MMSEA andlor MSP, I am
required to:
a. reimburse Medicare from the judgment/settlement herein for condttional
payments Medicare has made for treatment of injuries alleged in this action; and
b. utilize the judgment/settlement proceeds to pay for future medical expenses, when
those expenses are for care or treatment related to the injuries covered by the
allegations in this litigation.
5. I further acknowledge that the information provided herein will be relied upon by
defendant and OAG as true and accurate and, when applicable, willbe used for reporting
pursuant to Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 or as
deemed necessary or required by the defendant and OAG.
6. I hereby agree to promptly provide OAG with any and all information that OAG deems
necessary and required for its reporting pursuant to Section 111 of the Medicare, Medicaid and
SCHIP Extension Act of 2001.
PEDIGREE INFORMATION
7. I have been known by (include all alias name[s], former namefs] andlor maiden name[s])
the following names: [Jacob Rosado]. I hereby acknowledge that I can be identified by this/these
name(s) and all these names do, indeed, refer to me.
8. I consent to allow OAG to verify my current Medicare eligibility for purposes of its
compliance with Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007.
9. I affirm that:
a. my social security number is [1 ;
b. my date of birth is [ -95]; and
c. my gender is male.
2
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FILED: DUTCHESS COUNTY CLERK 08/16/2023 11:03 AM INDEX NO. 2021-53794
NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023
CURRENT MEDICARE
ELIGIBILITY
stcttus ?
Mediccre eligibility
? tnitial and alJitm appticaUte current
10 As of the date of this affidavit:
a. ,xlamnotcurrentlyeligibleforMedicarecovelageand/orbenefits
benefits;
coverage artdlot
nor have I ever received Medicare
OR
number IHIC #] is
b. / _ | am aMedicare Beneficiary, and my Medicarereimburse Medicare'
. I am u*u" oi*y obligation to
Advantage
@ c piun (also referted to as Medicare
plans or Medi-Gap Pi;;t and collectively referred to as
"Medicare") for payments
andlorbenefits that I ieceived directly or
indirectly from Medicare for medical
of this personal injury action' I
expenses for injuries ifrui *"." the sutject
understand that reimbursement directly
to Medicare may be made from proceeds I
personal injury action; and
receive from the f"Jg-""ysettlement] of this
owing
/- Medicare has confirmed that no payment is due and
(Attuch copy of
1.
from the total proceeds of the above-captioned litigation.
Demund Letter); or
Medicsre,s Cinditional Puyment letter and/or Finul
11. /_ Medicare has confitmed that it will accept the total amount
of$-'-asfullandfinalreimbursementofallMedicare
puy*""t" *ude to d ate. (Attach copy of Medicare's Conditional
Piyment Letter uncl/or Final Demsnd Letter). In accordance with the
attached Medicare letter, I consent to the payment of that sum directly
from the total proceeds of the above-captioned litigation; or
111 I am awaiting a conditional Payment Letter and/or Final
Demand Letter or equivalent information from Medicare' Upon my
receipt of the necessary documentation, I will promptly provide it to
[assigned AAG] and to OAG's Medicare Compliance Officer
via email at
Medicare.Compliance@,aq.nv.qov. I agree that no interest or penalty will
be assessed or demanded by me or on my behalf against the OAG for any
delay in payment pursuant to the tetms and conditions of the
ffudgmentisettlement] in the above-captioned litigation prior to OAG's
receipt of any and all necessary documentation from me issued by
Medicare (including but not limited to Medicare's Conditional Payment
Letter andlor Final Demand Letter). In accordance with Medicare's
Conditional Payment Leffer and/or Final Demand Letter (referred to,
respectively, as Medicare's Letter), I consent to the payment , directly
from the total proceeds of the judgment irVsettlement of the above-
captioned litigation, of the sum stated in Medicare's Letter as the sum that
Medicare will accept as fuI1 and final reimbursement of all Medicare
payments made to date.
J
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FILED: DUTCHESS COUNTY CLERK 08/16/2023 11:03 AM INDEX NO. 2021-53794
NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023
FUTURE MEDICARE ELIGIBILITY
? nitfat ancl ffirm applicablefuture Medicare eligibility status ?
1 1. As of the date of this affidavit:
a. /_X_ I do not expect to be Medicare eligible within 30 months of the
daG of this affidavit and as of the date of the fiudgment/settlementl of the above-
captioned litigation. I affirm that I:
i. I have not applied for social security disability (SSDI);
ii. have not been denied SSDI and anticipating appealing that decision;
iii. am not in the process of appealing or re-filing for SSDI;
iv. am not 62.5 yearc or older; and
v. do not have End Stage Renal Disease (a qualiflzing condition for
Medicare);
OR
b /_ I am not current a Medicare Beneficiary. However, I anticipate
thatJwill be Medicare eligible within 30 months of the date of this affidavit and
the date of the ftudgment/settlement] of the above-captioned litigation and
/ _ I do not require any future treatment for injuries that are the
subject of this personal injury action. The required certification(s) for the
injuries alleged in the [complaint/claim/bill of particulars - specify all
appltcable documentsJ is attached. The attached certification confirms
that there is no anticipated future treatment required for the injuries
sustained in the within personal injury action; or
ll /_ I do require future treatment for the injuries that are the
subject of this personal injury action. In accordance with the attached
Medicare Set-Aside Trust ("MSA"), I consent to the payment of
$ payable to from the total proceeds of the
above-captioned litigation. I affirm this sum will be used for future
medicalexpenses relating to the injuries of this personal injury action; or
iii. / I have not sought treatment for the injuries alleged in this
case and, as such, there are no medical expenses relating to the injuries
alleged herein. Furthermore, I do not anticipate seeking medical treatment
for injuries alleged in this action. I understand and agree that, if I require
future treatment andlor prescription medication for such injuries, I will use
the requisite amount of proceeds from the judgment inlsettlement of this
action to pay for any medical expenses relating to such injuries.
4
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NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023
c./ I am currently a Medicare Beneficiary and
I do not require any future treatment for injuries that are the
subject of this personal injury action. The required certification(s) for the
injuries alleged inthe [complaint/claim/bill of particulars - specify ull
applicable documentsJ is attached. The attached certification confirms
that no anticipated future fteatment is required for the injuries that are the
subject of this personal injury action; or
ii I do require future treatment for the injuries that are the
subject of this personal injury action. In accordance with the attached
Medicare Set-Aside Trust ("MSA"), I consent to the payment of
s payable to from the total proceeds of the
above-captioned litigation. I affirm this sum will be used for future
medical expenses relating to the injuries that are the subject of this
personal injury action; or
1ll. I have not sought treatment for the injuries alleged in this
case and, as such, there are no medical expenses relating to the injuries
alleged herein. Furthermore, I do not anticipate seeking medical treatment
for injuries alleged in this action. I understand and agree that, ifI require
future treatment and/or prescription medication for such injuries, I will use
the requisite amount of proceeds from the judgment inlsettlement of this
action to pay for any medical expenses relating to such injuries.
B ROSADO
Swom to before me this
i5 day ot' iur,.sl , 2tJ7:;.
MikaelAri Cohn
-, NOTARY PUBLIC, STATE OF NEW
Registration No. 02C06407824
Ulster County
Commissiqn Expires JulY 13, 2024
NOTARY PUBLIC
5
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Preview
FILED: DUTCHESS COUNTY CLERK 08/16/2023 11:03 AM INDEX NO. 2021-53794 NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023 Re r ,llur 20 l8 STATE OF NEW YORK SUPREME COURT DUTCHESS COUNTY JACOB ROSADO, Plaintiff, AFFIDAVIT OF -against STATUS OF MEDICARE ELIGIBILITY DEJUAN KOONCE, Index No. 53794-2021 Defendant. STATE OF NEW YORK ) ) SS. COLINTY OF DUTCHESS ) JACOB ROSADO being duly sworn, deposes and says: 1 . I am the plaintiff in the above-entitled action, I am a citizerr of lUnited States], I reside at [ , Poughkeepsie NY 12601) and my telephone number is 845- - 1. 2. I make this affidavit with full knowledge that it will be relied upon by the State of New York, its agents, employees and representatives ("OAG") in connection with settlement of this action against Dejuan Koonce and specifically as it relates to OAG's obligations to comply with the reporting requirements of Section 11 1 of the Medicare, Medicaid and SCHIP Extension Act of 2007 ("MMSEA") and the Medicare Secondary Payer Act ("MSP")' 3. I understand that a query has been / will be made pursuant to Section 111 of the Medicare,MedicaidandSCHIPExtensionActof200T,42[JS.C. 1395(BX8)toverifl,my current Medicare status. 1 of 5 FILED: DUTCHESS COUNTY CLERK 08/16/2023 11:03 AM INDEX NO. 2021-53794 NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023 4. I hereby acknowledge and understand that, as mandated by CMS and promulgated by and through its rules and regulations including but not limited to the MMSEA andlor MSP, I am required to: a. reimburse Medicare from the judgment/settlement herein for condttional payments Medicare has made for treatment of injuries alleged in this action; and b. utilize the judgment/settlement proceeds to pay for future medical expenses, when those expenses are for care or treatment related to the injuries covered by the allegations in this litigation. 5. I further acknowledge that the information provided herein will be relied upon by defendant and OAG as true and accurate and, when applicable, willbe used for reporting pursuant to Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 or as deemed necessary or required by the defendant and OAG. 6. I hereby agree to promptly provide OAG with any and all information that OAG deems necessary and required for its reporting pursuant to Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2001. PEDIGREE INFORMATION 7. I have been known by (include all alias name[s], former namefs] andlor maiden name[s]) the following names: [Jacob Rosado]. I hereby acknowledge that I can be identified by this/these name(s) and all these names do, indeed, refer to me. 8. I consent to allow OAG to verify my current Medicare eligibility for purposes of its compliance with Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007. 9. I affirm that: a. my social security number is [1 ; b. my date of birth is [ -95]; and c. my gender is male. 2 2 of 5 FILED: DUTCHESS COUNTY CLERK 08/16/2023 11:03 AM INDEX NO. 2021-53794 NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023 CURRENT MEDICARE ELIGIBILITY stcttus ? Mediccre eligibility ? tnitial and alJitm appticaUte current 10 As of the date of this affidavit: a. ,xlamnotcurrentlyeligibleforMedicarecovelageand/orbenefits benefits; coverage artdlot nor have I ever received Medicare OR number IHIC #] is b. / _ | am aMedicare Beneficiary, and my Medicarereimburse Medicare' . I am u*u" oi*y obligation to Advantage @ c piun (also referted to as Medicare plans or Medi-Gap Pi;;t and collectively referred to as "Medicare") for payments andlorbenefits that I ieceived directly or indirectly from Medicare for medical of this personal injury action' I expenses for injuries ifrui *"." the sutject understand that reimbursement directly to Medicare may be made from proceeds I personal injury action; and receive from the f"Jg-""ysettlement] of this owing /- Medicare has confirmed that no payment is due and (Attuch copy of 1. from the total proceeds of the above-captioned litigation. Demund Letter); or Medicsre,s Cinditional Puyment letter and/or Finul 11. /_ Medicare has confitmed that it will accept the total amount of$-'-asfullandfinalreimbursementofallMedicare puy*""t" *ude to d ate. (Attach copy of Medicare's Conditional Piyment Letter uncl/or Final Demsnd Letter). In accordance with the attached Medicare letter, I consent to the payment of that sum directly from the total proceeds of the above-captioned litigation; or 111 I am awaiting a conditional Payment Letter and/or Final Demand Letter or equivalent information from Medicare' Upon my receipt of the necessary documentation, I will promptly provide it to [assigned AAG] and to OAG's Medicare Compliance Officer via email at Medicare.Compliance@,aq.nv.qov. I agree that no interest or penalty will be assessed or demanded by me or on my behalf against the OAG for any delay in payment pursuant to the tetms and conditions of the ffudgmentisettlement] in the above-captioned litigation prior to OAG's receipt of any and all necessary documentation from me issued by Medicare (including but not limited to Medicare's Conditional Payment Letter andlor Final Demand Letter). In accordance with Medicare's Conditional Payment Leffer and/or Final Demand Letter (referred to, respectively, as Medicare's Letter), I consent to the payment , directly from the total proceeds of the judgment irVsettlement of the above- captioned litigation, of the sum stated in Medicare's Letter as the sum that Medicare will accept as fuI1 and final reimbursement of all Medicare payments made to date. J 3 of 5 FILED: DUTCHESS COUNTY CLERK 08/16/2023 11:03 AM INDEX NO. 2021-53794 NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023 FUTURE MEDICARE ELIGIBILITY ? nitfat ancl ffirm applicablefuture Medicare eligibility status ? 1 1. As of the date of this affidavit: a. /_X_ I do not expect to be Medicare eligible within 30 months of the daG of this affidavit and as of the date of the fiudgment/settlementl of the above- captioned litigation. I affirm that I: i. I have not applied for social security disability (SSDI); ii. have not been denied SSDI and anticipating appealing that decision; iii. am not in the process of appealing or re-filing for SSDI; iv. am not 62.5 yearc or older; and v. do not have End Stage Renal Disease (a qualiflzing condition for Medicare); OR b /_ I am not current a Medicare Beneficiary. However, I anticipate thatJwill be Medicare eligible within 30 months of the date of this affidavit and the date of the ftudgment/settlement] of the above-captioned litigation and / _ I do not require any future treatment for injuries that are the subject of this personal injury action. The required certification(s) for the injuries alleged in the [complaint/claim/bill of particulars - specify all appltcable documentsJ is attached. The attached certification confirms that there is no anticipated future treatment required for the injuries sustained in the within personal injury action; or ll /_ I do require future treatment for the injuries that are the subject of this personal injury action. In accordance with the attached Medicare Set-Aside Trust ("MSA"), I consent to the payment of $ payable to from the total proceeds of the above-captioned litigation. I affirm this sum will be used for future medicalexpenses relating to the injuries of this personal injury action; or iii. / I have not sought treatment for the injuries alleged in this case and, as such, there are no medical expenses relating to the injuries alleged herein. Furthermore, I do not anticipate seeking medical treatment for injuries alleged in this action. I understand and agree that, if I require future treatment andlor prescription medication for such injuries, I will use the requisite amount of proceeds from the judgment inlsettlement of this action to pay for any medical expenses relating to such injuries. 4 4 of 5 FILED: DUTCHESS COUNTY CLERK 08/16/2023 11:03 AM INDEX NO. 2021-53794 NYSCEF DOC. NO. 27 RECEIVED NYSCEF: 08/16/2023 c./ I am currently a Medicare Beneficiary and I do not require any future treatment for injuries that are the subject of this personal injury action. The required certification(s) for the injuries alleged inthe [complaint/claim/bill of particulars - specify ull applicable documentsJ is attached. The attached certification confirms that no anticipated future fteatment is required for the injuries that are the subject of this personal injury action; or ii I do require future treatment for the injuries that are the subject of this personal injury action. In accordance with the attached Medicare Set-Aside Trust ("MSA"), I consent to the payment of s payable to from the total proceeds of the above-captioned litigation. I affirm this sum will be used for future medical expenses relating to the injuries that are the subject of this personal injury action; or 1ll. I have not sought treatment for the injuries alleged in this case and, as such, there are no medical expenses relating to the injuries alleged herein. Furthermore, I do not anticipate seeking medical treatment for injuries alleged in this action. I understand and agree that, ifI require future treatment and/or prescription medication for such injuries, I will use the requisite amount of proceeds from the judgment inlsettlement of this action to pay for any medical expenses relating to such injuries. B ROSADO Swom to before me this i5 day ot' iur,.sl , 2tJ7:;. MikaelAri Cohn -, NOTARY PUBLIC, STATE OF NEW Registration No. 02C06407824 Ulster County Commissiqn Expires JulY 13, 2024 NOTARY PUBLIC 5 5 of 5