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Workers' Comp and Medicare: Can You Get Both?

By Daniel Taylor, Esq. on December 02, 2014 12:59 PM

For an older worker hurt on the job, a potential workers' compensation claim may have an added wrinkle: Medicare.

Medicare is the federal health care program that provides medical benefits to those 65 or older, as well as some people younger than 65 who are on disability. Workers' compensation, on the other hand, provides benefits to those who are injured on the job, including paying for medical treatment for work-related injuries.

So what happens when a worker may be eligible for both?

Medicare Is Secondary Payer

When Medicare and another type of insurance such as workers' compensation may both provide coverage for medical expenses, there are "coordination of benefit" rules that decide which insurance will be the primary payer and which insurance will be the secondary payer.

When an injured worker is eligible for both Medicare and workers' compensation, workers' comp will be considered the primary payer for medical expenses related to an employment injury, with Medicare being the secondary payer. This means that Medicare will not pay for items or services that workers' compensation will pay for promptly. But Medicare may make conditional payments for when workers' compensation denies payment of medical bills.

Medicare may also cover the the portion of medical bills not covered by workers' comp when an injury is only partially covered by worker's compensation.

Medicare Set-Aside Arrangements

Medicare also may affect the settlement of a workers' compensation claim. In addition to repaying Medicare for any payments made for services related to your claim, the settlement may also need to provide funds to be set aside for future services related to your claim that would have been covered by Medicare in a Workers' Compensation Medicare Set Aside Arrangement (WCMSA).

The money placed into this fund must be used to pay medical expenses related to the injury until it is exhausted, with Medicare covering further expenses. A WCMSA is only required when a claim is settled, however, and will not be required when a claim is resolved by a judgment or award of benefits.

To learn more about recovering for job related injuries, head over to FindLaw's section on Workers' Compensation Basics.

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