Medicare and workers’ compensation

What does Medicare have to do with Workers’ Compensation and my work injury?

If you suffered a work injury and the workers’ compensation Insurance company has accepted liability for your work injury then the insurance company is responsible for medical bills that are reasonable and necessary for treatment of your work injury. Please keep in mind that what is reasonable and necessary and related to your work injury are legal conclusions based an the application of the law to your specific case.

Generally, when someone is disabled they can receive Social Security Disability or Supplemental Security Income. At a certain point they become Medicare eligible. What types of medical expenses Medicare pays for can be found on various government websites. However, if someone is disabled due to a work injury and receives Social Security Disability or Supplemental Security Income, under The Medicare Secondary Payor Act, generally, one cannot shift the responsibility for payment of medical expenses for a work injury onto Medicare.

Medicare should not be paying for medical expenses for an accepted work injury that are the responsibility of the workers’ compensation insurance carrier. If Medicare has made payments of medical expenses for your work injury, also kown as conditional payments, then they should be reimbursed by the workers compensation insurance carrier.

If an injured worker wants to settle future medical expenses, in other words close out the workers’ compensation insurance carrier’s obligation to pay for future medical expenses for the work injury, for whatever reasons (usually in exchange for a lump sum of money), then approval by Medicare is generally necessary. In order to do that in most cases a Medicare Set Aside needs to be approved by Medicare. Worker Compensation Medicare Set Asides are complicated but generally a lump sum of money that has been calculated to cover future medical expenses for your work injury for the rest of your life such that Medicare can reasonably expect it will cover those expenses and not have to pay for you work injury related medical prescriptions and medical expenses is to be put into a separate bank account for payment of those medical expenses.

For questions regarding Workers’ Compensation, Work Related Injuries, Social Security Disability, Supplemental Security Income, as well as interactions with Medicare feel free to contact us.

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