There can be a delay between when a bill is filed for the work-related illness or injury and when the workers' compensation insurance decides if they'll pay the bill. Medicare can't pay for items or services that workers' compensation will pay for promptly (generally 120 days). Medicare may make a
if the workers' compensation insurer denies payment for your medical bills pending a review of your
(generally 120 days or longer).
This isn't the same as when your workers' compensation case has been settled and you're using Workers' Compensation Medicare Set-aside Arrangement (WCMSA) funds to pay for your medical care. See below for more information on WCMSAs.
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. Workers' compensation insurance may agree to pay only a part of your bill if both of these are true:
- You had an injury or illness before you started your job (called a "
- The job made it worse
This is because the job didn't cause the original problem. 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.
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, you must use the settlement money to pay for related medical care before Medicare will begin again to pay for related care. In many cases, before a settlement is reached, the workers' compensation agency asks Medicare to approve an amount to be set aside to pay for future medical care. Medicare will look at certain medical documentation and approve an amount of money from the settlement. This money must be used up first before Medicare starts to pay for related care that's otherwise covered and reimbursable by Medicare.
You and the workers' compensation agency aren't required to set up a WCMSA—it's completely voluntary. However, you must make sure the settlement money is used only for related medical care. To get approval for a proposed WCMSA account for you to manage, or for more information about WCMSAs, visit go.cms.gov/wcmsa.
Using money in your WCMSA
To find out how to manage (self-administer) your WCMSA account, visit go.cms.gov/WCMSASelfAdm. Keep these in mind:
- 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 and otherwise reimbursable items and services related to your workers' compensation claim.