Does Medicare Cover Auto Accident Injuries?

Medicare is a federal health insurance program serving millions of eligible individuals across the United States. It provides healthcare coverage for people aged 65 or older, younger people with certain disabilities, and individuals with End-Stage Renal Disease (ESRD). Understanding how this program interacts with medical costs from auto accidents is important for beneficiaries. This article explores how Medicare handles medical expenses incurred due to auto accident injuries.

Scope of Medicare Coverage for Auto Injuries

Medicare can provide coverage for medically necessary treatment following an auto accident. Medicare Part A and Part B may cover related medical services if you sustain injuries in a car crash. These services must meet Medicare’s medical necessity criteria and be provided by Medicare-approved healthcare professionals and facilities.

Medicare Part A, which covers inpatient hospital care, can help with costs if your injuries require admission to a hospital for surgery or other intensive treatments. Similarly, Medicare Part B, covering outpatient services, generally pays for doctor visits, diagnostic tests like X-rays, ambulance services, and medically necessary durable medical equipment. It also includes various therapies, such as physical or occupational therapy. Medicare coverage for these services is subject to standard beneficiary cost-sharing requirements, including deductibles and coinsurance amounts. While Medicare can cover these expenses, its role often depends on other available insurance, which affects the order of payment.

Medicare’s Secondary Payer Status

Medicare generally operates as a secondary payer when other insurance coverage is available to address medical expenses from an auto accident. This means that Medicare typically pays only after other responsible parties or insurance policies have fulfilled their payment obligations.

Several types of auto insurance act as primary payers before Medicare. These include auto liability insurance, which covers damages caused by an at-fault driver, and no-fault insurance policies, such as Personal Injury Protection (PIP) or Med-Pay coverage, which pay for medical expenses regardless of fault.

In situations where a primary payer has not yet made payment, or payment is delayed, Medicare may make a “conditional payment.” This conditional payment allows beneficiaries to receive necessary medical treatment without delay. Medicare expects to be reimbursed for these conditional payments once the primary insurance pays or a settlement, judgment, or award is secured. For instance, if a no-fault insurer does not pay a claim within 120 days, Medicare might step in to cover the costs.

Reporting an Auto Accident to Medicare

If you are a Medicare beneficiary involved in an auto accident, reporting the incident to Medicare is a necessary step. This notification helps Medicare coordinate benefits with any other insurance coverage you might have. Federal law requires beneficiaries to report such claims to Medicare, even if no personal injury lawsuit is immediately filed.

To facilitate this process, you should contact the Benefits Coordination & Recovery Center (BCRC), which manages these inquiries for Medicare. When reporting, provide specific details about the accident. This information includes the date of the injury or accident, a description of the alleged injury, and details about all involved insurance policies.

If you have legal representation, the BCRC will also require your attorney’s name and contact information. Providing this information promptly allows Medicare to track any payments it makes and determine if another payer is primarily responsible.

Medicare Reimbursement Procedures

Medicare has a legal right to seek reimbursement for any conditional payments it makes for auto accident injuries when another party is responsible. This right is often referred to as a “Medicare lien” on any settlement, judgment, or award received by the beneficiary.

Once a settlement or judgment is reached, the BCRC identifies all related payments Medicare has made. They then issue a Conditional Payment Letter (CPL), which details the amount Medicare believes it is owed. Beneficiaries or their legal representatives can review this letter and dispute any charges that are unrelated to the accident injuries.

Federal law requires Medicare to be reimbursed from the settlement funds. Failure to comply with these reimbursement obligations can lead to penalties, including potential double damages. The final amount owed to Medicare is typically deducted from the settlement before the remaining funds are disbursed to the beneficiary. Medicare may also reduce its claim to account for the beneficiary’s attorney fees and other procurement costs associated with securing the settlement.