Medicare and Medicaid

If you are considering a workers’ comp settlement, it is important to know such a settlement is entirely voluntary on your part. You do not have to agree to a proposed settlement offer and your employer and its workers’ comp insurer do not have to agree to settle your claim. If you are considering a settlement, you must know exactly what benefits you are entitled to as well as what rights you may be relinquishing.

Many employers will propose a settlement for your permanent partial disability by offering a dollar amount roughly equivalent to what you would receive under your normal workers’ comp claim. The difference is you will be required to give up something in return. That something could be the right to argue you are permanently and totally disabled, or the right to future medical care. If you receive a workers’ comp settlement, you may also be required to reimburse any payments made by Medicare or Medicaid relating to your work injury. 

Other Times During a Workers’ Comp Claim When Medicare May Pay

Aside from receiving a workers’ comp settlement, in some cases there may be a delay between the time you file a workers’ comp claim and the time you actually begin to receive benefits. Medicare is not allowed to pay for items or services which workers’ comp will pay for within 120 days. If your workers’ compensation claim is denied, however, Medicare may be allowed to make a conditional payment. You would be required to provide Medicare with proof the claim was denied. If workers’ comp denied part of your claim due to a pre-existing condition, you and the workers’ comp insurer might agree to share the medical expenses, and your part could be paid by Medicare, if you are covered.

How a Workers’ Comp Settlement Affects Medicare or Medicaid 

If you later proceed with a settlement of your workers’ comp claim, you might need to repay Medicare for any payments received by Medicare for workers’ compensation claim-related services. If you have an attorney, you might want to ask him or her to set up a Workers’ Compensation Medicare Set-aside Arrangement in which your settlement funds will be deposited into. If you are managing your own Workers’ Compensation Medicare Set-aside Arrangement, you must remember that any money placed in the account is for future medical or prescription drug expenses related to your work injury which would have been covered by Medicare.

You are not allowed to use these funds for another injury or for any medical expenses not covered by Medicare. Medicare will not pay for any of your medical expenses which are related to your work injury until all the set-aside money has been used in an appropriate manner. You must keep careful records of your medical expenses, clearly showing the services you received or money spent on services related to your work injury or illness. When your WCMSA account has been depleted, Medicare will resume paying for your medical expenses.

Could Medicaid Recover Rules Hamper Your Ability to Settle Your Case?

Like Medicare, the Mississippi state Medicaid program can seek reimbursement for medical expenses paid to the Medicaid beneficiary when that person receives a workers’ compensation settlement. Some feel the Medicaid recovery rules might hamper workers’ ability to settle workers’ comp cases, and that the recovery rules are not entirely balanced and fair. Medicaid programs are only allowed to collect reimbursement from the medical portion of a Mississippi workers’ comp settlement, leaving the lost wage payments and other damages to the worker.

Although Medicare reimbursement liens can be confirmed, there is no central clearinghouse to determine whether a workers’ comp claimant owes money to the Mississippi state Medicaid program, which can create problems when a settlement comes through. Further, while Medicare allows workers’ comp settlements to cover legal fees prior to being subject to reimbursement, it is uncertain whether Medicaid does the same. If Medicaid does not allow workers’ comp settlements to cover legal fees prior to reimbursement, the worker’s attorney might not get paid.