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Does Medicare/Medicaid Cover Injuries From a Car Accident?

If you’ve been injured in a crash, it’s important to understand your coverage

Medicare and Medicaid are government programs that provide health insurance coverage to specific groups of Americans. Medicare primarily serves individuals 65 and older, while Medicaid assists low-income individuals.

If you’re a beneficiary involved in a Texas car accident, questions may arise about your coverage. Understanding how they apply to compensation for your injuries is important before filing a claim.

An experienced Houston car accident lawyer at Smith & Hassler can help you explore your options for seeking compensation so you don’t have to pay out of pocket.

What are the differences between Medicare and Medicaid coverage?

Medicare is a federal program primarily for people 65 years of age or older, regardless of income.

It also covers some younger individuals with specific disabilities or conditions, such as End-Stage Renal Disease or Amyotrophic Lateral Sclerosis. Medicare is divided into different parts:

  • Part A covers hospital stays.
  • Part B covers outpatient care and medical supplies.
  • Part C (Medicare Advantage) offers an alternative way to receive Medicare benefits.
  • Part D covers prescription drugs.

Conversely, Medicaid is a joint federal and state program that provides health coverage to eligible low-income individuals. Unlike Medicare, Medicaid eligibility is primarily based on income and financial resources rather than age. It covers a wider range of healthcare services, including long-term care, which Medicare generally doesn't cover.

In Texas, Medicaid is administered by the Texas Health and Human Services Commission. Texas hasn’t expanded Medicaid under the Affordable Care Act, which means eligibility criteria are more restrictive than in some other states. It requires recipients to be both low-income and belong to a specific category, such as children, pregnant women, or disabled adults.

Can I get Medicare and Medicaid coverage after a car accident?

Medicare and Medicaid cover injuries resulting from car accidents, but important caveats exist. Most notably, these programs typically make what are called "conditional payments" for your medical care.

This means they pay for your treatment up front, with the expectation of being reimbursed if you receive a settlement from the at-fault driver's insurance provider.

When and why to use Medicare or Medicaid for compensation after a car accident depends on several factors. For example, you can get necessary medical treatment immediately after a crash. This way, you don't have to delay care while waiting for insurance issues to be sorted out.

Plus, if the at-fault driver is uninsured or underinsured, or there are delays in determining fault, Medicare or Medicaid can cover your initial medical expenses.

How do I file a personal injury claim in Texas while on Medicare or Medicaid?

If you're a Medicare or Medicaid beneficiary injured in a car accident that wasn't your fault, you have the right to file a personal injury claim against the responsible party. This allows you to seek compensation for your losses (damages), including medical expenses, lost wages, and pain and suffering.

Filing a car accident claim becomes more complicated when Medicare or Medicaid is involved. These programs add additional steps and requirements to the standard claims process. For example, you must report your claim to Medicare or Medicaid as soon as you file it. This reporting initiates the process of identifying payments made by these programs.

You should seek medical attention immediately after your car accident and inform your healthcare providers that your injuries are related to your collision claim. Then, consult with an experienced car accident attorney who is experienced in handling cases involving Medicare or Medicaid beneficiaries in Texas.

Your attorney can help you gather all necessary documentation and file your personal injury claim within Texas's two-year statute of limitations. They can also notify Medicare or Medicaid about your claim, which is required by law. This notification starts the process of identifying any payments these programs have made related to your injury.

Just be aware that any settlement you receive must satisfy the Medicare or Medicaid lien before you can access the remaining funds.

How are Medicare and Medicaid liens determined?

The lien amount is based on the medical expenses paid by Medicare or Medicaid that are directly related to your car accident injuries.

Medicare uses a specific formula to calculate post-treatment reimbursement. This is designed to ensure that Medicare recovers a fair portion of its costs while also allowing you to retain a reasonable amount of the settlement. This formula takes into account several factors:

  • The total amount of the settlement.
  • Attorney fees and other procurement costs.
  • The amount Medicare paid for injury-related treatments.

Both Medicare and Medicaid may initially include unrelated medical expenses in their lien calculations. For example, If you had a pre-existing condition that required treatment during the same period as your car accident-related care, those costs might be initially included in the lien.

Additionally, the lien amount can be subject to negotiation in some cases. Negotiation strategies might include:

  • Demonstrating that certain treatments were unrelated to your car accident.
  • Arguing for a reduction based on comparative fault if you were partially responsible for the car accident.
  • Requesting a reduction based on procurement costs.
  • In some cases, applying for a hardship waiver.

These programs may include charges for treatments unrelated to your collision in their initial lien calculations because of clerical errors or misunderstandings about the nature of certain treatments.

It's important to carefully review all records and charges to ensure that only crash-related expenses are included in the final lien amount. However, verifying all charges can be particularly challenging if you don’t have any medical expertise.

An attorney can help identify discrepancies, dispute unrelated charges, and ensure that the final lien amount accurately reflects only the necessary medical care.

How does the Medicare and Medicaid reimbursement process work in a car accident claim?

When you receive a settlement from the other driver’s insurance company, you are legally obligated to reimburse Medicare or Medicaid for the medical expenses they covered related to your car accident. This process is known as "paying back the lien," and it must be completed before you can access the remaining settlement funds.

Failing to repay Medicare or Medicaid can have serious consequences:

  • The federal or state government may sue you and your attorney for double damages plus interest.
  • You could lose your Medicare or Medicaid coverage.
  • Criminal charges may be filed in severe cases.
  • Other penalties, such as fines, may be imposed.

Consult an attorney who can protect your rights and maximize your settlement

If you were involved in a car accident in Texas, you’re likely dealing with injuries and recovery, as well as medical bills and other related expenses. The last thing you probably want to deal with is a complex claim involving Medicare or Medicaid. However, an experienced Texas car accident lawyer can handle that for you.

At Smith & Hassler, we have the legal knowledge and experience to guide you through this challenging process and ensure that your rights are protected. Our car accident lawyers are well-versed in the nuances of Medicare and Medicaid liens, reporting requirements, and reimbursement processes.

We can help you avoid costly mistakes that could jeopardize your benefits or result in severe penalties. We can also review your case, explain your potential legal options, and fight tirelessly to maximize your compensation.

To get started, contact us online and set up a free, no-obligation case evaluation. You can also call our law offices in Houston or Channelview. If you can’t come to us, we can come to you.

Click here to download a printable PDF of this article, "Does Medicare/Medicaid Cover Injuries From a Car Accident?"

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