Workers’ compensation insurance is needed to pay for medical care for your industrial injuries as long as you need that care, sometimes for life. Thus, even if you are not on Medicare when you are injured, you may become eligible for Medicare sometime later, when the workers’ compensation insurance is still responsible for medical care to some part or parts of your body.

In the recent years, several states have provided that workers compensation claims can be settled. Such claims operate the same manner to settlements in civil cases. A claimant can resolve the indemnity and medical portions of the claim. To be more specific about it, Medicare is starting to review workers compensation settlements and believes that there has been an illegal shift of medical benefits from workers compensation insurers to Medicare.

If the workers’ compensation insurance in a specific state denies payment, and if you give Medicare proof that the claim was denied, Medicare will pay for Medicare-covered items and services.

There are cases however where 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:

  • The job made it worse
  • You had an injury or illness before you started your job (called a ” pre-existing condition“)

This is because the job did not 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 the Claim

If you want to settle workers’ compensation claim, you together with 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.

WCMSA- Workers’ Compensation Medicare Set-aside Arrangements

A Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) is a financial agreement that allocates a portion of a workers’ compensation settlement to pay for future medical services related to the workers’ compensation injury, illness, or disease.  These funds must be depleted before Medicare will pay for treatment related to the workers’ compensation injury, illness, or disease.

If the workers’ compensation claim is settled, you need to use the settlement money to pay for related medical care first before Medicare begins to pay for related care. In most cases, prior to reaching a settlement, the workers’ compensation agency asks Medicare to approve an amount to be set aside to pay for future medical care.

Medicare will consider certain medical documentation and decides on the amount of money from the settlement. This money should be used up before Medicare starts to pay for related care that is otherwise covered and reimbursable by Medicare.