Medicare & Workers Compensation

Long Beach Attorneys Explain
Medicare & Workers Compensation

The average American worker does not begin to collect Medicare until the time they retire. So they typically rely on employer-provided health insurance benefits while employed – and Medicare after they retire.

But, in the case of disabled employees who are receiving Workers’ Compensation benefits, the situation is quite different. An injured worker who is collecting workers’ comp may eventually become eligible for Medicare, while their workers’ compensation insurance is still responsible for covering medical care for their work-related injury or illness.

In this article our experienced Long Beach workers’ compensation attorneys explain how Medicare and Workers’ Compensation interact – and how your medical claims should be handled if you are receiving both.

Who Pays My Medical Bills, Workers Compensation or Medicare?

Workers’ compensation is always the “primary payer” for any medical care for injuries or illnesses that occurred at (or were caused by) the workplace.

Medicare is considered a “secondary payer.” That means that if any other insurance (including workers’ compensation) is supposed to cover a medical bill, then Medicare does not have to cover it.

So your doctors should be billing the workers’ compensation insurance company for any treatments related to your work injury – and not Medicare – even if you also have Medicare.

In situations where Medicare does end up paying for treatment that is found to be a work injury, Medicare will be entitled to be reimbursed by the workers’ compensation insurance company.

This sounds straightforward – but a big problem can arise in situations where the worker has settled their future medical care by a lump sum buyout (Compromise and Release).

When a worker settles a workers’ compensation case and accepts a lump sum dollar amount that releases the workers’ comp insurance from all future responsibility for medical care, Medicare still DOES NOT cover any work-related treatments. In other words, Medicare won’t pay the work-related bills because they consider them to have been already “paid” (in advance) by the buyout sum.

Further, Medicare does not even calculate how much money from your settlement was for medical care and how much was for permanent disability (or other things). For example, if a buyout settlement was for $250,000.00, Medicare will claim “credit” for that whole amount, even if a portion of that lump sum of it was intended to be for permanent disability benefits and not medical care. So they will deny coverage for $250,000 of medical bills related to the workplace injury or illness.

Workers’ Compensation & Medicare Set Aside

There is a way around the problem of coordinating Workers’ Compensation & Medicare, but it is complicated. For this reason, if you are considering a lump sum buyout, it is important to discuss your situation with an experienced workers’ compensation attorney. An experienced workers’ compensation lawyer can help you understand and assess all of the benefits you are entitled to – so that you can maximize the value of the claim.

A Medicare Set Aside is a method of protecting Medicare’s interest in any workers’ compensation settlement that might involve them. First an analysis of the worker’s potential future medical costs – Medicare Set Aside (MSA) Analysis – is done. This is a projection based on the last two years of medical care and on the predictions of treating physician(s) as to what care is likely to be needed in the future.

Once the MSA analysis has been done it is submitted to the Center for Medicare Services (CMS) which will review it – and make a decision if they think it is reasonable. Then the CMS will either accept the proposal – or recommend a higher amount.

Once Medicare accepts an amount as reasonable, the worker must keep that amount separate and spends it only for agreed upon work-related medical care. Once the worker spends the account completely down, Medicare will then (and only then) begin covering the medical care for the work injury.

The worker has to put the MSA money into a federally insured, interest bearing account – and keep it separate. They can only use that account to pay medical bills that Medicare (or workers’ compensation) would otherwise have paid. If they do not spend all the money before they die, then the money goes to their heirs.

Long Beach Workers’ Compensation Attorneys

Our experienced Long Beach Workers’ Compensation attorneys have helped thousands of men and women across Orange County and Los Angeles collect the workers’ compensation they deserve. If you have question about workers’ compensation, our lawyers will be happy to help you understand your options, and make the best decision to ensure you receive the full amount of benefits to which you are entitled.

Call our Long Beach Workers’ Compensation attorneys for a free consultation.

Long Beach Workers Compensation Attorneys: 562-622-4800