Medicare: What is it and what are the rules?

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Medicare is the federal government's healthcare program. It covers qualifying individuals age 65 or older or those under age 65 who are disabled, suffering from permanent kidney failure, or diagnosed with Lou Gehrig's disease. Medicare does not pay for long-term care, but it does pay for a portion of necessary medical expenses and hospitalizations.

The rules governing Medicare eligibility are based on a combination of factors: your age, how long you've worked, and how much Social Security tax (or "FICA") you've paid throughout your work history. For instance, if you've worked up to 20 out of 40 calendar work quarters, depending on your age, you've likely paid a sufficient amount of Social Security tax into the system to qualify for Medicare.

For those who are disabled and meet the criteria, they often begin receiving Medicare two years after being approved for any kind of Social Security disability or SSD benefit. This is different than Supplemental Security Income (SSI) which is discussed in another video. The SSD system was created to provide disability insurance for injured workers and their families. Once a worker (who has paid a sufficient amount into the Social Security system) cannot hold a substantial job for at least 12 months, he or she is eligible for SSD.

If you qualify, Medicare may be your main source of healthcare coverage. If that's the case, Medicare will pay for your injury-related care when another party is responsible. But, if you are able to recover from the party responsible for your injury, you must repay Medicare for the injury-related care. Medicare technically refers to their reimbursement right as a "reimbursement claim" because the program has a have a priority right to reimbursement that is stronger than any other lien. However, to keep it simple, we will refer to Medicare's right of recovery as a lien. Federal law requires all parties to "consider Medicare's interests" in third party settlements where Medicare has made what are called "conditional payments" for injury-related care.

The term "conditional payments" describes the injury-related healthcare payments Medicare made for your treatment, although another party caused — and is legally responsible for — your injury. Medicare makes the payment on the condition that the responsible party pay the program back for that treatment. Because Medicare made the payment on the condition that it be paid back, if you receive a personal injury settlement, Medicare must be reimbursed out of your settlement proceeds before any money can be sent to you.

A federal law called The Medicare Modernization Act of 2003 put the obligation on you and your attorney to inform Medicare of any possible situation where Medicare made a "conditional payment."

Keep in mind that Medicare is not required to send notice of its lien to you. Rather, you or your attorney will need to request a conditional payment summary, then analyze, audit, and resolve Medicare's claims for reimbursement. The Garretson Resolution Group will do this for you, if your attorney has hired us to resolve the healthcare liens in your case.

Medicare: What is it and what are the rules?

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