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.