If you’ve tuned into the television recently, you’ve probably seen commercial after commercial reminding you about the Medicare Annual Enrollment Period and to check your plan.
The Annual Enrollment Period runs from October 15 through December 7 each year, allowing beneficiaries to make changes to their plan without penalty. Your coverage changes won’t take effect until January 1, but if you’re considering joining or switching, now’s the time. During this enrollment, you may be able to take advantage of new additions that weren’t available when you originally took out coverage.
If you’re already on Medicare, you can also choose to keep your existing coverage.
One of the top questions you might have about Medicare is whether it covers you if you’re injured in a car accident. In this blog, we explain everything you need to know about the enrollment deadline and what Medicare pays for, including whether it covers auto accident injuries.
Does Medicare Cover Medical Care After a Car Accident?
If you’re a Medicare beneficiary who’s been hurt in a car accident, you’re looking at emergency room bills, follow-up appointments, maybe physical therapy or surgery, and you need to know whether your Medicare card is going to work.
Medicare can cover your accident-related medical expenses. But, crucially, it almost never pays first.
Medicare only steps in when other sources are exhausted or have legitimate reasons for denying coverage. This is federal law, codified at 42 U.S.C. § 1395y(b), and it overrides state laws and private insurance contracts.
Before Medicare will pay a single dollar toward your accident care, your auto insurance needs to step up and fulfill its obligations. If you have Personal Injury Protection (PIP) or Medical Payments (MedPay) coverage on your policy, those benefits take priority. If another driver caused the crash, their liability insurance comes before Medicare, too.
This payment order is established by federal law under the Medicare Secondary Payer (MSP) statute, and it applies whether you’re on an Original Medicare or a Medicare Advantage plan. If you’ve been injured in a Texas car accident, it’s important to understand where you potentially stand to avoid complications (and avoidable stress) when it comes to paying your bills.
The system exists to protect Medicare’s resources and make sure that insurance policies designed to cover injuries do what they’re supposed to.
Medicare is a taxpayer-funded program serving over 65 million Americans. Without MSP rules, insurance companies could shift costs to Medicare even when their policies were supposed to cover the claim. If you got hurt in a car accident, your auto insurer could argue, “The patient has Medicare, so Medicare should pay,” and Medicare would end up footing the bill that the auto policy was designed to handle.
Does the Payment Order Really Matter?
Treatment providers might bill Medicare first by mistake. You might be thinking, “As long as my bills get paid, does it really matter who writes the check?” Unfortunately, it can, potentially affecting your credit, delaying your treatment, and leaving you fielding calls from collection agencies.
When Medicare is billed, your policy provider will check its records, see that you have auto insurance or that another party was at fault, and deny the claim outright. That denial goes back to your doctor’s office or the hospital, and now they’re stuck with an unpaid bill.
They have to resubmit your treatment bill to the correct insurer, but by this point, weeks or months may have passed. Some providers will wait patiently, but others will send you to collections, report the debt to credit bureaus, or demand payment from you directly while the insurance companies argue over who is liable for covering the debt.
Even if your providers are patient and your credit stays intact, billing errors create delays. Every denied claim has to be researched, resubmitted, and tracked. Your doctor’s billing staff has to coordinate between multiple insurance companies, each with different rules and timelines. Meanwhile, you’re receiving threatening letters about unpaid balances, spending hours on the phone trying to straighten everything out, and wondering why something that should be simple has turned into a bureaucratic nightmare.
The best solution is to ensure every provider that treats you for your accident-related injuries knows about all your insurance coverage from day one. Give them your Medicare card and your auto insurance information at the same time. Let them know another driver was at fault, if that’s the case. The few minutes you spend providing this information upfront can save you months of problems later, some of which can have lasting effects on your financial health.
How Medicare Actually Works as a Secondary Payer
Medicare is a “secondary payer,” but how does this work in practice?
If you’re in a car accident and need emergency treatment, the ambulance might take you to the hospital, where you receive care and are eventually discharged with instructions for follow-up. The hospital needs to get paid for the services provided.
Assuming you have Medicare and auto insurance coverage, the hospital must bill your auto insurance first, according to MSP rules.
If another party was at fault, your insurer may honor the claim and then seek to recover the amount from the at-fault party, in a process called insurance subrogation.
Alternatively, if you speak to a car accident attorney and have a claim, your lawyer can provide a Letter of Protection (LOP), which temporarily resolves the problem of paying your medical bills immediately. An LOP effectively provides your treatment provider with a guarantee that your expenses will be paid when your claim is resolved.
Only after your auto insurance benefits are exhausted or denied can the hospital bill Medicare for the remaining covered costs.
How Do These Rules Apply to Different Medicare Parts?
The secondary payer rules apply across all parts of Medicare, but what are each of these parts for?
Medicare Part A
Medicare Part A handles inpatient hospital care. If your accident injuries are severe enough to require hospitalization, whether an initial stay immediately after your accident or a subsequent admission for surgery, Part A would ordinarily cover those costs. But under MSP rules, Part A won’t apply until your auto insurance benefits are exhausted.
The hospital’s billing department will need to bill your PIP, MedPay, or other policies first. After those sources are exhausted, the hospital can submit the remainder to Medicare Part A. You’ll still be responsible for your Part A deductible and any coinsurance.
Medicare Part B
Medicare Part B covers the bulk of what most accident victims need: emergency room treatment, doctor visits, outpatient care, diagnostic tests, and physical therapy.
If you need X-rays, MRIs, or CT scans to diagnose your injuries, that’s covered by Part B, along with follow-up appointments with your doctor or a specialist, physical therapy to regain mobility, and medical equipment such as crutches, a wheelchair, or a back brace.
As with Part A, your providers must bill your primary policies before Medicare will step in.
Medicare Part D
Medicare Part D covers prescription medications, and the rules work a bit differently. Most auto insurance policies don’t cover take-home prescription medications. They might cover medication administered during emergency treatment or a hospital stay, but once you’re sent home with prescriptions for pain medication, muscle relaxers, anti-inflammatories, or antibiotics, you’re often left to foot the bill.
Because of this, Part D plans can act as the primary payer for accident-related prescriptions. However, if your auto policy does include prescription coverage (as some comprehensive policies do), then Part D would, like other Parts, come second.
Medicare Advantage Plans
Medicare Advantage plans (Part C) follow the same secondary payer rules as Original Medicare. The main difference between Medicare Advantage and Original Medicare is that each plan type has unique procedures for coordinating benefits.
After an accident, you should contact your Medicare Advantage plan provider directly to report your injuries and ask about their specific requirements for filing claims. Some plans have stricter rules about which medical providers you can seek treatment from, and there may be specific procedures for submitting documentation or authorization required for certain services.
Many Medicare Advantage plans also include extra benefits that Original Medicare doesn’t cover, such as chiropractic care, acupuncture for pain management, gym memberships, and transportation to medical appointments. If you need any of these services after an accident, check your plan to see what’s covered and, crucially, whether your auto insurance needs to be billed first.
What Medicare Won’t Cover (Even After an Accident)
Medicare coverage inevitably has its limitations, and these apply regardless of how you were injured. The program won’t pay for services it doesn’t ordinarily cover, so the only way to ensure full coverage is to purchase supplemental coverage ahead of time, pay out of pocket, or pursue compensation through a personal injury claim against the at-fault party.
Common exclusions include:
- Dental care: If you suffered dental injuries in your accident, such as chipped teeth, broken teeth, or damage to dental work, Medicare won’t cover the repairs. There are extremely limited exceptions for dental procedures that are integral to other covered medical procedures (like reconstructing your jaw before radiation treatment for oral cancer), but routine accident-related dental damage doesn’t fall into those exceptions.
- Long-term custodial care: If your accident injuries leave you needing ongoing help with daily living activities (bathing, dressing, eating, toileting, transferring in and out of bed, etc.) Medicare won’t pay for someone to provide assistance over the long term.
- Vision and hearing services: Medicare doesn’t cover routine eye exams, glasses, or contact lenses, even if your vision was affected by the accident. Similarly, Medicare doesn’t cover hearing aids or the exams to fit them, even if you suffered hearing damage in the crash.
When Medicare Can Cover You Temporarily
By definition, Medicare will only pay out after your other policies. But a common scenario is that a person is injured in an accident and needs immediate medical care, but their insurer is taking its time processing their claim. The adjuster might be investigating liability, requesting additional documentation, or generally dragging their heels.
Even though your auto insurance is primary and should pay first, Medicare can make what’s called a conditional payment to ensure your providers get paid promptly and that you don’t end up in collections or have treatment delayed while waiting for the auto insurer to act.
A conditional payment is exactly what it sounds like: Medicare pays your medical bills with the condition that it will be reimbursed later once the primary payer resolves the claim. By law, auto insurers are supposed to pay claims “promptly,” which federal regulations define as within 120 days of receiving all necessary information. When an insurer doesn’t meet that timeline, Medicare has the authority to step in and make conditional payments so that your care isn’t disrupted.
How Does Medicare Affect a Personal Injury Claim?
If you’re considering filing a personal injury claim against the driver or party that caused your accident and Medicare has stepped in to cover your treatment via a conditional payment, you’ll need to pay Medicare back. Whatever the amount you owe (a lien) will affect how much money you’ll receive from a settlement or judgment, so the process must be handled correctly and with care.
Let’s say you settle your case for $50,000. That might sound like a substantial amount, but before you see any of that money, several things need to happen. Your attorney will take their fee (typically one-third of the settlement, and you’ll need to reimburse Medicare for its conditional payment. On top of this, there might be additional liens from health insurance or medical providers. By the time you account for attorney fees, Medicare reimbursement, and other costs, you might be looking at considerably less than your gross settlement amount.
This is why experienced personal injury attorneys factor Medicare liens into settlement negotiations from the beginning. If your lawyer knows Medicare has paid $15,000 in conditional payments, they’ll work to secure a settlement large enough to cover the reimbursement and your attorney fees, while leaving you with meaningful compensation for your pain and suffering, lost wages, and other damages.
What You Need to Know If You’re Injured in Texas
If you’re injured in a car accident in Texas caused by someone else’s negligence, you have the right to file a personal injury claim to recover compensation for all your losses. These include:
- Medical expenses (both past and future)
- Lost wages
- Property damage
- Pain and suffering
- Mental anguish
- Loss of enjoyment.
But the process can be even more confusing if you’re partly responsible for the crash that caused your injuries. Common examples of joint negligence include driving too slowly when you are rear-ended by a tailgating driver or being momentarily distracted, meaning you couldn’t react in time to avoid a crash.
Texas follows a modified comparative negligence rule with a 51% bar. In simple terms, this means you can still recover damages if you are partly liable, as long as you are not 51% or more at fault for the crash. Your compensation is then reduced by your percentage of fault, so if you are deemed 30% responsible, you will recover 70% of your final settlement or judgment. However, if you are more than 51% liable, you can’t recover anything.
If you have relied on Medicare to cover your treatment costs and you’re partly at fault for your accident, you will receive a reduced amount of compensation if your claim is successfully resolved. This must be factored in to ensure you can cover your liens.
You should also keep in mind the statute of limitations, which is how long you have to file a personal injury lawsuit. In Texas, you have two years from the date of the accident to bring a claim. This deadline is strict, and if you miss it, you lose your right to pursue compensation, regardless of how strong your case is or how badly you were injured.
If you’re a Medicare beneficiary who has been injured in a car accident in Texas, Patino Law Firm is here to help. We can assess whether you have a claim, explain your rights in plain English (or Spanish — se habla Español), and pursue the maximum compensation you’re entitled to. We can also help you figure out where you stand with paying for your medical treatment, whether you have Medicare, an alternative policy, or need a Letter of Protection to reduce the burden while you focus on recovery, and we focus on resolving your claim.
You can call us 24/7 at 855-LAW-NINJA or submit a contact form. We serve the Rio Grande Valley from our office in McAllen, Greater San Antonio, and the Permian Basin from our Odessa office, but we can also come to you. You won’t pay fees until we win.
