Medicare is a government health insurance program that primarily covers individuals age 65 or older. Medicare will pay for medical bills after an accident, but should the recipient obtain a personal injury settlement or court award, Medicare usually has the right to obtain reimbursement of funds paid for any medical treatment connected with the accident that led to the claim. These are what Medicare calls "conditional payments"—Medicare makes them on the condition that it will be able to recover them should the Medicare recipient get some sort of reimbursement from a third party (like a defendant or an insurance company).
Let's look at what you can expect as a Medicare recipient who is also a personal injury claimant with a reasonable likelihood of obtaining a settlement or other recovery.
If you get into an accident that requires medical treatment for personal injuries, you will most likely need to report the accident to the Benefits Coordination and Recovery Center (BCRC). The BCRC’s primary purpose is to make sure Medicare gets reimbursed for payment of funds for which another entity may bear ultimate responsibility.
For example, if you get into a car accident and suffer injuries, there’s a good chance that someone’s car insurance policy will end up paying for your medical bills. Therefore, Medicare may ask for reimbursement of anything it pays that the car insurance company should pay for.
When reporting the accident to the BCRC, you will need to include the following information:
If you don’t report the accident, there’s a good chance Medicare will find out about it anyway. That’s because Medicare will see your medical bills and be able to identify injuries that are often the result of an accident. Medicare will then probably reach out to you and ask for the above-listed information. If you do not cooperate and provide this information, you risk losing your Medicare eligibility.
After you report the accident, Medicare will monitor your case and may start collecting information about it. The BCRC will then send you a Rights and Responsibilities (RAR) Letter.
The RAR Letter identifies any additional information you need to provide, and what you can expect from the BCRC.
Within 65 days of issuing the RAR Letter, the BCRC will send you a Conditional Payment Letter (CPL) and Payment Summary Form (PSF). Both of these will list what the BCRC believes you should reimburse Medicare for, as well as information on how to dispute payments you believe do not relate to the accident.
If you disagree with what the BCRC identifies in the CPL and PSF, you will need to provide the BCRC with additional documentation that supports your position. The BCRC may take up to 45 calendar days to review your disagreement and make a decision.
If you are able to win or settle your case, you will need to notify the BCRC. In most personal injury lawsuits, it will be your attorney that notifies the BCRC. This notification must include:
The BCRC will then check to see if there are any additional payments Medicare made that should be reimbursed. You will then receive a formal recovery demand letter specifying the amount you owe Medicare.
If you disagree with the amount in the formal demand letter, you have 120 days to request an appeal. You can do this by sending a letter and supporting documentation that explains why you disagree with the demand amount.
If you believe you shouldn't have to pay the amount demanded, you can ask the BCRC for a waiver of recovery, but this rare remedy is usually only granted if:
Interest will begin accruing from the date of the formal demand letter. Even if you file an appeal or request a waiver, interest will continue to accrue on the amount Medicare says you owe.
If you do not pay what Medicare demands, or otherwise ignore the formal demand letter, Medicare may refer your debt to the Department of Justice or the Department of Revenue for additional legal or collection proceedings.
If things get complicated and you'd like to understand your rights and options when dealing with Medicare after an injury settlement, it might make sense to discuss your situation with a personal injury lawyer.