As the number of older Americans increase in the workforce, a question that often comes up is can you claim workers’ compensation if you have Medicare? The answer is yes, but the process is a little different. Federally funded Medicare provides benefits to those aged 65 and older or for younger people if they are on disability. State funded workers’ comp provides benefits to anyone who is injured while on the job. In the situation of an individual with Medicare (or someone who will be eligible for Medicare within the next 30 months) being hurt on the job claiming workers’ comp benefits is largely the same but with a couple of differences, starting with the coordination of benefits and who pays first.
Workers’ Comp pays first, Medicare pays second
When a worker that gets injured is eligible for both Medicare and workers’ compensation, the primary payer for medical bills will be workers’ comp.If they don’t swiftly make payment within 120 days, then Medicare generally steps in and makes a conditional payment.The conditional payments rests upon whenever workers’ compensation determines what they will cover or a settlement is made. At that time, Medicare is to be paid back their contribution.
If workers’ comp denies coverage and it is a Medicare-covered service, then Medicare will pay on a non-conditional basis. That means you don’t have to pay Medicare back later. There are also instances where workers’ comp will pay for only a portion of the medical care, such as if you had a preexisting condition that the injury made worse. In that case, Medicare will pay for any Medicare-covered services which workers’ comp did not cover.
Settling Workers’ Comp Claim
If you intend to settle your workers’ comp claim, you must set aside a fund to repay Medicare. This is called a Workers’ Compensation Set-aside Arrangement (WCMSA). The amount of the WCMSA is determined case-by-case and the fund can be used for future bills and to pay back Medicare. It is against the law to shift the burden from workers’ comp to Medicare for a work injury, so Medicare could deny payment for treatment related to the work injury if you do not exhaust your set-aside fund properly first. It is in your best interest to retain a workers’ comp lawyer for both assistance with settling your claim and for understanding the set-aside fund agreement. Your lawyer will contact Medicare and coordinate benefits and come up with the amount you must repay.
When exactly would I need a WCMSA?
Any settlement that includes an amount for future medical expenses must include Medicare’s interest in it.If the WCMSA meets the thresholds below, then you must submit it for review at the Centers for Medicare and Medicaid Services (CMS) and get approval.
- If you are already receiving Medicare, and the total workers’ comp settlement amount is more than $25,000 OR
- You are expected to be a Medicare beneficiary in the next 30 months and the total settlement (including expected future medical costs/disability/lost wages is expected to be more than $250,000
The bottom line is that if you are considering settling your workers’ comp claim and there is a Medicare set-aside involved, you must work with an experienced lawyer who can guide you to maximize your claim and protect your legal rights. Both the Medicare system and the workers’ comp system are incredibly confusing, and you deserve to get what you are owed for the claim. The only way to ensure this is by seeking the advice experienced counsel.