Will a Workers’ Compensation Award Affect My Medicare Payments?

Injured workers may be eligible for both workers’ compensation and Medicare. Whether Medicare affects workers’ compensation depends on whether the employee is seeking payment for medical expenses before or after the case is settled. Silverman, McDonald & Friedman has the experience to coordinate your Medicare payments with your work injury payments.  Call our offices in Newark, Seaford, or Wilmington to discuss your rights.

Medicare payments before a workers’ compensation settlement

Medicare may pay for hospital bills, doctor visits, and other expense if the employer’s insurance company doesn’t pay the bill. Generally, if the employee is eligible for workers’ compensation, the insurance company will pay first. If the claim is denied or if only a portion of the medical bill is paid by workers’ compensation, then Medicare should pay for expenses the program covers. Claims may be denied or paid only partially:

  • If the worker was not an employee
  • If the accident did not happen during the scope of the worker’s employment
  • If the worker had a pre-existing condition

Generally, Medicare will not pay for medical expenses that the employer’s carrier should pay within 120 days. If a claim is not paid within 120 days, Medicare may make a conditional payment. The condition is that Medicare must be reimbursed if the employer’s carrier does ultimately pay the medical expense.

Settlements and Medicare Set Asides

Workers may consider settling their claim, with the help of experienced Delaware workers’ compensation lawyers, once they have reached maximum medical improvement (MMI). MMI is the point when additional medical treatment is not expected to improve your medical condition.

Workers and their lawyers need to contact Medicare to determine if Medicare should be reimbursed for any medical payments it made, and how much money should be set aside for future payments. Before a worker will be able to ask Medicare to pay any of his/her medical expenses, the worker will need to use funds that have been set aside for medical bills. Medicare must agree to the amount that is being set aside based on the worker’s medical needs and his/her Medicare eligibility requirements.

A Workers’ Compensation Medicare Set Aside Arrangement (WCMSA) is voluntary. It does generally avoid confusion and any contests with Medicare. Workers’ compensation settlements usually have two parts – the funds for medical bills and the lost income amount the worker is entitled to receive. Workers can learn more about how an WMCSA works by visiting go.cms.gov/wcmsa.

The basics of a Workers’ Compensation Medical Set Aside are:

  • The money set aside for medical bills and prescription drug cost should be used – just for medical bills and prescription drug cost – that relate to your workplace injury or illness. The money is for the expenses that Medicare would have paid if workers’ compensation didn’t cover the expenses.
  • The money should not be used for expenses Medicare doesn’t cover. It’s wise to check with Medicare regarding which services and treatments they do and don’t cover.
  • Workers should keep records of the physicians they see, the prescriptions they use, and the charges for these items to prove that they did use their WCMSA money for legitimate expenses.

Medicare should pick up your medical bills after you use up your WCMSA and provided you are eligible.

At Silverman, McDonald & Friedman, we fight for injured workers in Delaware. This fight includes contesting efforts to force you back to work too soon. It includes working with your doctors to understand your immediate and long-term medical needs. We negotiate settlements that reasonably anticipate the medical care you will need. We work with Medicare to set aside enough so that you can claim Medicare when you need it. Call our Delaware workers’ compensation lawyers at 302.314.5553 or use our contact form. to speak with a respected work injury lawyer. Our offices are located in Wilmington, Newark, and Seaford.