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Home :: FAQ :: Medicare and Medicaid

So, are there limits on Medicare’s recovery of health insurance benefit payments made on my behalf if I have available Liability or Workers, Compensation insurance available and my case has not yet settled?

Yes.  When a Medicare beneficiary is injured Medicare will pay for accident related expenses normally covered by private insurance companies including automobile insurance and Workers’ Compensation coverage, but only when payments from private insurance sources cannot be expected to be promptly made.

Liability Cases

In liability Cases Medicare will look to the recipient to reimburse Medicare for payments Medicare has made for accident related expenses that were made prior to the settlement of the personal injury case.  As of 12/01/11 there was no requirement that a litigant reimburse Medicare for future injury related medical expenses.  If this were to occur, then, as it presently does in Workers’ Compensation cases, Medicare could require “Set-Aside” Arrangements.

Workers’ Comp

In Workers Comp cases where there is no dispute over liability, and the case is to be settled in a lump sum of WC benefits,  MSP (Medicare Second Payer) and CMS (Centers for Medicare and Medicaid Services) will require a “Medicare Set - Aside Arrangement requiring CMS approval of the Settlement or Set-Aside to assure that the injured beneficiary’s future medical expenses will not be paid for by Medicare but from the proceeds actually and reasonably set aside by the recipient as a consequence of the settlement.

There is a different rule that applies to Lump Sum Se3ttlements that are a compromise of a WC claim that the parties have negotiated which is less than the full amount of total compensation or where there is a bonified dispute as to liability.  See 42 C.F.R Section 411.46 generally and www.cms.hhs.gov/Manuals/IOM .