I have Medicare and filed a workers’ compensation claim. Who pays first? If you have Medicare and get injured on the job, workers’ compensation pays first on health care items or services you got because of your work-related illness or injury. There can be a delay between when a bill is filed for the work-related illness or injury and when the state workers’ compensation insurance decides if they should pay the bill. Medicare can’t pay for items or services that workers’ compensation will pay for promptly (generally 120 days). However, if the workers’ compensation insurer denies payment for your medical bills pending a review of your claim (generally 120 days or longer), Medicare may make a conditional payment. This isn’t the same situation as when your workers’ compensation case has been settled and you’re using funds from your Workers’ Compensation Medicare Set-aside Arrangement (WCMSA) to pay for your medical care. See next page for more information on WCMSAs.

 

If you think you have a work-related illness or injury, tell your employer, and file a workers’ compensation claim. You or your lawyer also need to call the BCRC toll-free at 1-855-798-2627 as soon as you file your workers’ compensation claim. TTY users should call 1-855-797-2627.

 

Example: Tom was injured at work. He filed a claim with workers’ compensation insurance. His doctor billed the state workers’ compensation insurance for payment. Tom’s doctor didn’t get paid within 120 days, so he billed Medicare and sent a copy of Tom’s workers’ compensation claim with the claim for Medicare payment. Medicare made a conditional payment to the doctor for the health care services Tom got. When a settlement is reached with the state workers’ compensation agency, Tom must make sure Medicare gets its money back for the conditional payment.

 

How does Medicare get its money back for the conditional payment? If Medicare makes a conditional payment, and you or your lawyer haven’t reported your worker’s compensation claim to Medicare, call the Benefits Coordination & Recovery Center (BCRC) toll-free at 1-855-798-2627. TTY users should call 1-855-797-2627. The BCRC will work on your case, using the information you or your representative gives it to see that Medicare gets repaid for the conditional payments. The BCRC will gather information about any conditional payments Medicare made relating to your pending settlement, judgment, award or other payment. Once a settlement, judgment, award or other payment is final, you or your lawyer should call the BCRC. The BCRC will get the final repayment amount (if any) on your case and issue a letter requesting repayment.

 

What if I want to settle my workers’ compensation claim? You or your lawyer should contact the BCRC. Settlements of workers’ compensation claims are handled differently than a settlement of a no-fault or liability insurance claim. As part of settling your workers’ compensation claim, you must repay Medicare for any Medicare payments for workers’ compensation claim-related services you already got.

 

When and why would I need a Workers’ Compensation Medicare Set-aside Arrangement (WCMSA)? If you settle your worker’s compensation claim, the settlement may provide for funds to be set aside to pay for future medical and prescription drug expenses related to your injury, illness or disease. When you have Medicare, you may wish to ask your workers’ compensation lawyer about the possibility of setting up a Workers’ Compensation Medicare Set-aside Arrangement (WCMSA) for depositing these funds. The WCMSA ensures workers’ compensation funds are spent on these future expenses otherwise covered by Medicare. In other words, workers’ compensation pays before Medicare for these future expenses. If you have a WCMSA as part of your workers’ compensation settlement, you must be careful how you spend money specifically set aside for Medicare. You or your lawyer need to send your proposed WCMSA to the BCRC at: WCMSA Proposal/Final Settlement P.O. Box 138899 Oklahoma City, OK 73113-8899

 

 How am I allowed to use the money in my Workers’ Compensation Medicare Set-aside Arrangement (WCMSA) if I manage (self-administer) the account? Keep these in mind if you manage your WCMSA account: • Money placed in your WCMSA is for paying future medical expenses, including prescription drug expenses related to your work injury or illness/disease that otherwise would have been paid back by Medicare. You should also use WCMSA funds to pay for these medical services and items, as well as prescription drug expenses, if you’re enrolled in a Medicare Advantage Plan. • You can’t use the WCMSA to pay for any other work injury, or any medical items or services that Medicare doesn’t cover (like dental services). • Medicare won’t pay for any medical expenses related to the injury until after you have used all of your set-aside money appropriately. • If you aren’t sure what type of services Medicare covers, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for more information, before you use any of the money that was placed in your WCMSA account. TTY users should call 1-877-486-2048. • Keep records of your workers’ compensation-related medical expenses, including prescription drug expenses. These records show what items and services you got and how much money you spent on your work-related injury, illness, or disease. You need these records to prove you used your WCMSA money to pay your workers’ compensation-related medical expenses, including prescription drug expenses. • After you use all of your WCMSA money appropriately, Medicare can start paying for Medicare-covered services related to your work-related injury, illness, or disease.

 

What if workers’ compensation denies payment? If workers’ compensation insurance denies payment, and you give Medicare proof that the claim was denied, Medicare will pay for Medicare-covered items and services as appropriate.

 

Example: Mike was injured at work. He filed a workers’ compensation claim. The workers’ compensation agency denied payment for Mike’s medical bills. Mike’s doctor billed Medicare and sent Medicare a copy of the workers’ compensation denial with the claim for Medicare payment. Medicare will pay Mike’s doctor for the Medicare-covered items and services Mike got as part of his treatment. Mike must pay for anything Medicare doesn’t cover. 

 

Can workers’ compensation decide not to pay my entire bill? In some cases, workers’ compensation insurance may not pay your entire bill. If you had an injury or illness before you started your job (called a “pre-existing condition”), and the job made it worse, workers’ compensation may not pay your whole bill because the job didn’t cause the original problem. In this case, workers’ compensation insurance may agree to pay only a part of your doctor or hospital bills. You and workers’ compensation insurance may agree to share the cost of your bill. If Medicare covers the treatment for your pre-existing condition, then Medicare may pay its share for part of the doctor or hospital bills that workers’ compensation doesn’t cover.

 

Source of information: www.Medicare.gov