There can be a delay between when a bill is filed for the work-related illness or injury and when the state workers' compensation insurance decides if they should pay the bill. Medicare can't pay for items or services that workers' compensation will pay for promptly (generally 120 days). However, if the workers' compensation insurer denies payment for your medical bills pending a review of your claim (generally 120 days or longer), Medicare may make a conditional payment.
If the state workers' compensation insurance denies payment, and if you give Medicare proof that the claim was denied, then Medicare will pay for Medicare-covered items and services.
In some cases, workers' compensation insurance may not pay your entire bill. If you had an injury or illness before you started your job (called a " pre-existing condition"), and the job made it worse, workers' compensation may not pay your whole bill because the job didn't cause the original problem. In this case, workers' compensation insurance may agree to pay only a part of your doctor or hospital bills. You and workers' compensation insurance may agree to share the cost of your bill. If Medicare covers the treatment for your pre-existing condition, then Medicare may pay its share for part of the doctor or hospital bills that workers' compensation doesn't cover.
If you think you have a work-related illness or injury, tell your employer, and file a workers' compensation claim. You or your lawyer also need to call the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627. TTY users should call 1-855-797-2627.
Settle your workers' compensation claim
If you want to settle your workers' compensation claim, you or your lawyer should contact the recovery contractor. Settlements of workers' compensation claims are handled differently than a settlement of a no-fault or liability insurance claim. As part of settling your workers' compensation claim, you must repay Medicare for any Medicare payments for workers' compensation claim-related services you already got.
Workers' Compensation Medicare Set-aside Arrangements (WCMSA)
If you settle your workers' compensation claim, the settlement may provide for funds to be set aside to pay for future medical or prescription drug services related to your injury, illness, or disease. When you have Medicare, ask your workers' compensation lawyer to set up a Workers' Compensation Medicare Set-aside Arrangement (WCMSA) to deposit these funds into.
Using money in your WCMSA
If you manage (self-administer) your WCMSA account, keep the following in mind:
Workers' compensation claims can be resolved by settlements, judgments, or awards. This information applies only to settlements.
- Money placed in your WCMSA is for paying future medical and/or prescription drug expenses related to your work injury or illness/disease that otherwise would have been covered by Medicare.
- You can't use the WCMSA to pay for any other work injury, or any medical items or services that Medicare doesn't cover (for example, dental services).
- Medicare won't pay for any medical expenses related to the injury until after you have used all of your set-aside money appropriately.
- If you aren't sure what type of services Medicare covers, call Medicare before you use any of the money that was placed in your WCMSA.
- Keep records of your workers' compensation-related medical and prescription drug expenses. These records show what items and services you got and how much money you spent on your work-related injury, illness or disease. You need these records to prove you used your WCMSA money to pay your workers' compensation-related medical and/or prescription drug expenses.
- After you use all of your WCMSA money appropriately, Medicare can start paying for Medicare-covered services related to your work-related injury, illness, or disease.