Workers’ compensation is a state-administered program that pays for health care and other claims for job-related injuries. If you have Medicare and file for workers’ compensation, workers’ compensation pays primary for any care related to your accident or injury.
If workers’ compensation does not make a decision about paying your health care bills within 120 days, Medicare may make conditional payments. A conditional payment is when Medicare temporarily pays in place of workers’ compensation. Then, once your workers’ compensation claim is settled or a final decision or award is reached, Medicare must be paid back for payments it made that were for services related to the accident or injury.
If workers’ compensation denies coverage for a Medicare-covered service, Medicare should pay for your care on a non-conditional basis, meaning you will not have to pay Medicare back at a later date.
Sometimes workers’ compensation will not pay for all the care you need for a job-related injury. For example, workers’ compensation might only pay for part of your care if you have a preexisting condition and your job-related injury made the preexisting condition worse. In this case, Medicare should pay for any Medicare-covered services that are not paid for by your workers’ compensation.
When you file a claim with your workers’ compensation insurer, you should also call the Medicare coordination of benefits contractor at 800-999-1118 and report the claim.
If you plan to settle your workers’ compensation claim, it is important to set aside funds in a special account called a Workers’ Compensation Medicare Set-Aside Agreement. This account can be used to pay future medical bills related to your injury and to repay Medicare for any of its conditional payments. You will need a lawyer’s assistance to settle your claim and create this set-aside agreement account. Before reaching a workers’ compensation settlement, your lawyer should typically contact the Medicare coordination of benefits contractor to get Medicare approval of the amount you plan to put in the account.
You must typically use all the money in your set-aside agreement account for medical bills related to your injury before Medicare will start paying for care related to your injury. You or the organization that manages the account should keep track of how the money in the account is used to prove to Medicare that the account funds were only used to pay for injury-related medical and prescription drug bills.
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