Medicare Requirements in Personal Injury Claims

Starting on January 1, 2011, personal injury claims from claimants eligible for Medicare must be reported to Medicare.  Medicare is entitled to a 100% recovery of the benefits it paid for the treatment of injuries and it will seek reimbursement of such payments from any settlement or payout on the claim.  Failure to comply with the reporting or reimbursement requirements can result in a fine of $1,000 per day plus interest and double damages.

Personal injury claims must be reported if the claims are eligible for Medicare or are reasonably expected to be eligible within thirty months.  People eligible for Medicare have to be U.S. citizens or legal permanent residents, and include people at least 65 years old and individuals with certain disabilities who qualify for Social Security Disability Insurance benefits.

To determine whether a claimant is a Medicare beneficiary, a query should be sent to the Centers for Medicare and Medicaid Services (CMS) through their website. The CMS has 14 days to respond.

Reporting thresholds. There are minimum reporting thresholds to be met before payments need to be reported.  These thresholds decrease over time.  In 2012, payments totaling a minimum of $2,000 must be reported.

Who must report. The entities eligible to report include anyone making a payment to a Medicare beneficiary on a settlement, judgment or award.  The entities include insurers, self-insured entities and several other entities.

What must be reported. If the claimant is entitled to Medicare, the reporting entity must report information about the claimant and their claim once it is resolved. Medicare must be reimbursed within 60 days after the claim is resolved.

If the claimant receives a payout and Medicare is not reimbursed, Medicare can initiate legal action against the claimant as well as the reporting entity.  The reporting entity can be liable to reimburse Medicare even if it already paid the claimant for the same expenses for which Medicare is seeking reimbursement.  The reporting requirements still hold if the parties agree that a personal injury payout does not include paying for medical expenses.