Medicare and Workers’ Compensation

You didn’t see that coming, did you? Medicare and workers’ compensation don’t seem to have anything to do with one another. Yet for an increasing number of injured workers, Medicare is very much a part of their workers’ compensation case.

Workers’ Compensation—a Quick Recap

Workers' compensation covers injuries incurred “arising out of” and “in the course of” employment. Breaking that down to layperson’s terms, it means if you are performing your expected job functions and get hurt, it should be covered under workers’ comp.

While there are many exceptions, the general gist is that if you are doing your job and get hurt, you’re covered. Sure, there are situations where you’re doing something that is not in your job description and where you arguably wouldn’t be covered. There are also a plethora of “parking lot cases” involving everything from tripping and slipping in the lot on the way to or after work, and these often hinge on specific facts (was it an employee-only lot? Was the employee at an “increased risk” from the general public?).

And don’t get me started on cases involving travel between jobs. Most of the time, these injuries are covered. Often, they may yield both a workers’ compensation case AND a third party personal injury case, in situations such as a car crash in between job appointments.

As highlighted in prior blog posts, workers’ compensation pays three basic things: medical benefits, time off from work in the form of TTD or Temporary Total Disability, and PPD, or Permanent Partial Disability. There are other permanency options too in limited circumstances, such as PTD (Permanent Total Disability), or wage differential cases. But that is the basic thumbnail recitation of what the Illinois Workers’ Compensation Act covers.

How is Medicare Involved?

In some situations, the doctor anticipates that the injured worker will require future medical treatment. Okay, great. Why would Medicare care? Well, they don’t, in most cases. Future medical care would be either covered by workers’ compensation if the case is tried to an arbitration decision and medical is kept “open,” or if it is settled with medical left open.

But if the injured worker is “of a certain age,” Medicare gets VERY interested in this future treatment.

In short, if the worker is age 62.5 or older, or is a current Medicare recipient AND there is future medical treatment anticipated, then Medicare’s interests MUST be taken into account.

How is this done?

With something called an MSA, or Medicare Set Aside. Essentially, an independent auditor reviews the injured worker’s medical file and determines what future treatment might be contemplated and the cost (to Medicare) of that treatment. This can encompass everything from a future surgery, a series of injections, or even a requisite number of pain pills in a given year. Then, they calculate the anticipated life expectancy of the worker and come up with a dollar amount that must be “set aside” for this purpose.

The money is usually held by the insurer for the employer. The worker is responsible for keeping track of all post-settlement medical treatment related to the injuries that were a part of the case, and logs and receipts must be sent in to the insurer regularly. As monies are expended for future treatment, the MSA money is used to “reimburse” Medicare.

Seriously? Does This Make Sense to Anyone?

In theory, it makes sense. Medicare is on the hook to pay for something that arguably should be part of the workers’ compensation case. So the MSA lays out money for making sure Medicare doesn’t “go negative” in paying for all this.

In reality, it is a giant pain in the butt for insurers, petitioner’s attorneys, and injured workers. It is more confusing than anything else, and a bookkeeping headache.

But Medicare has an automatic right to have its interests protected, so that’s why MSAs exist.

Takeaways

• Workers’ compensation and Medicare go together like peanut butter and banana, believe it or not
• Not every case qualifies, but a Medicare Set Aside must be initiated if the injured worker has anticipated future medical treatment and is of a threshold age or is a recipient of Medicare
• MSAs protect Medicare and also set aside money for the injured worker’s future treatment

Contact Chicago Personal Injury Lawyer Stephen Hoffman

As in all cases involving injury, workers’ compensation, or other injury and potential liability, if you have been injured at work, contact a lawyer with expertise in your type of case, such as workers’ compensation or motor vehicle accidents.

If you've been in an accident and have questions, contact Chicago personal injury attorney Stephen L. Hoffman for a free consultation at (773) 944-9737. Stephen has over 30 years of legal experience and has collected millions of dollars for his clients. He is listed as a SuperLawyer, has a 10.0 rating on Avvo, and is BBB A+ accredited. He is also an Executive Level Member of the Lincoln Square Ravenswood Chamber of Commerce.

Stephen handles personal injury claims on a contingency fee basis, which means you don’t pay anything up front and he only gets paid if you do. Don’t wait another day; contact Stephen now.