Medicare and Medicaid

Aside from receiving a workers’ comp settlement, in some cases there may be a delay between the time you file a workers’ comp claim and the time you actually begin to receive benefits. Medicare is not allowed to pay for items or services which workers’ comp will pay for within 120 days. If your workers’ compensation claim is denied, however, Medicare may be allowed to make a conditional payment. You would be required to provide Medicare with proof the claim was denied. If workers’ comp denied part of your claim due to a pre-existing condition, you and the workers’ comp insurer might agree to share the medical expenses, and your part could be paid by Medicare, if you are covered.

How a Workers’ Comp Settlement Affects Medicare or Medicaid

If you later proceed with a settlement of your workers’ comp claim, you might need to repay Medicare for any payments received by Medicare for workers’ compensation claim-related services. If you have an attorney, you might want to ask him or her to set up a Workers’ Compensation Medicare Set-aside Arrangement in which your settlement funds will be deposited into. If you are managing your own Workers’ Compensation Medicare Set-aside Arrangement, you must remember that any money placed in the account is for future medical or prescription drug expenses related to your work injury which would have been covered by Medicare.

You are not allowed to use these funds for another injury or for any medical expenses not covered by Medicare. Medicare will not pay for any of your medical expenses which are related to your work injury until all the set-aside money has been used in an appropriate manner. You must keep careful records of your medical expenses, clearly showing the services you received or money spent on services related to your work injury or illness. When your WCMSA account has been depleted, Medicare will resume paying for your medical expenses.