TN 12 (10-89)
Payment under Medicare may not be made for any items and services to the extent that
payment has been made or can reasonably be expected to be made for such items or services
under a workers' compensation (WC) law or plan of the United States or a State. Any
Medicare payment made for items or services which can be or could have been paid for
under WC constitutes an overpayment.
This limitation is applicable to the WC plans of the 50 States, the District of Columbia,
Guam, Puerto Rico, American Samoa and the Virgin Islands. It also applies to the Federal
plans provided under the Federal Employees' Compensation Act, the U.S. Longshoremen's
and Harbor Workers' Compensation Act and its extensions, and the Federal Coal Mine
Health and Safety Act of 1969 as amended (the Federal Black Lung program).
These Federal programs provide WC protection for Federal civil service employees and
certain other categories of employees not covered, or not adequately covered, under
State programs; e.g., coal miners totally disabled due to pneumoconiosis, maritime
workers (with the exception of seamen), employees of companies performing overseas
contracts with the United States government, employees of American companies who are
injured in an armed conflict, employees paid from nonappropriated Federal funds (such
as employees of post-exchanges), and offshore oil field workers.
The Federal Employers' Liability Act, which covers merchant seamen and employees of
interstate railroads, is not a WC law or plan for purposes of this limitation .
The beneficiary is responsible for taking whatever action is necessary to obtain payment
under WC where payment under that system can reasonably be expected. (e.g., timely
filing a claim and furnishing all necessary information). If failure to take proper
and timely action results in a loss of WC benefits, Medicare benefits are not payable
to the extent that payment could reasonably have been expected under WC.
For the effect of payment by WC on provider services see HI 01201.040C. For the effect on physicians' and suppliers' services see HI 01201.040D and E.